Introduction to global health [3 ed.] 9781284123890, 1284123898

Table of contents :
Cover
Introduction To Global Health
Copyright
Contents
Preface
New to This Edition
About the Author
Chapter 1 Global Health Transitions
1.1 Defining Global Health
1.2 Health Interventions
1.3 Prevention Science
1.4 Health Transitions
1.5 World Regions and Featured Countries
1.6 Global Health Security
1.7 Globalization and Health: Shared Futures
References
Chapter 2 Global Health Priorities
2.1 Global Health Achievements
2.2 Prioritization Strategies
2.3 Health Metrics
2.4 Millennium Development Goals
2.5 Sustainable Development Goals
References
Chapter 3 Socioeconomic Determinants of Health
3.1 Health Disparities and the SDGs
3.2 Economics
3.3 Education
3.4 Gender
3.5 Employment
3.6 Minority Populations
3.7 Migrant and Refugee Health
3.8 Governance and Politics
References
Chapter 4 Environmental Determinants of Health
4.1 Environmental Health and the SDGs
4.2 Water, Sanitation, and Hygiene
4.3 Energy and Air Quality
4.4 Occupational and Industrial Health
4.5 Urbanization
4.6 Sustainability
4.7 Climate Change and Health
References
Chapter 5 Health and Humans Rights
5.1 Health and Human Rights
5.2 Access to Basic Human Needs
5.3 Access to Health Services
5.4 Access to Medicines
5.5 Health and Natural Disasters
5.6 Conflict and War
5.7 Bioterrorism
5.8 Health in Prisons
5.9 People with Disabilities
References
Chapter 6 Global Health Financing
6.1 Personal and Public Health
6.2 Health Systems
6.3 Paying for Personal Health
6.4 Health Insurance
6.5 Paying for Global Health Interventions
6.6 Official Development Assistance
6.7 Multilateral Aid
6.8 Foundations and Corporate Donations
6.9 Personal Donations
References
Chapter 7 Global Health Implementation
7.1 Global Health Interventions
7.2 Local and National Governments
7.3 International Cooperation
7.4 The World Health Organization and the United Nations
7.5 International Health Regulations
7.6 Global Partnerships
7.7 The Nonprofit Sector
7.8 The Corporate Sector
7.9 Research and the Academic Sector
7.10 Measuring Impact
References
Chapter 8 HIV/AIDS and Tuberculosis
8.1 HIV/AIDS, TB, and Global Health
8.2 Viruses, Bacteria, and Fungi
8.3 HIV and AIDS
8.4 HIV/AIDS Epidemiology
8.5 HIV Interventions
8.6 Other Sexually Transmitted Infections
8.7 Tuberculosis
8.8 TB Interventions
8.9 Antimicrobial Resistance
References
Chapter 9 Diarrheal, Respiratory, and Other Common Infections
9.1 Infectious Diseases and Global Health
9.2 Diarrheal Diseases
9.3 Diarrhea Interventions
9.4 Pneumonia
9.5 Other Respiratory Infections
9.6 Influenza
9.7 Immunization
9.8 Vaccine-Preventable Infections
9.9 Viral Hepatitis
9.10 Meningitis
References
Chapter 10 Malaria and Neglected Tropical Diseases
10.1 Malaria, NTDs, and Global Health
10.2 Parasites: Protozoa and Helminths
10.3 Malaria
10.4 Malaria Interventions
10.5 Dengue and Other Arboviruses
10.6 Chagas Disease and Trypanosomiasis
10.7 Leishmaniasis
10.8 Schistosomiasis
10.9 Lymphatic Filariasis
10.10 Onchocerciasis
10.11 Leprosy, Buruli Ulcer, and Trachoma
10.12 Rabies
10.13 Soil-Transmitted Helminths
10.14 Other Neglected Tropical Diseases
10.15 Eradication
10.16 Emerging Infectious Diseases
References
Chapter 11 Reproductive Health
11.1 Reproductive Health and Global Health
11.2 The Fertility Transition
11.3 Population Planning
11.4 Family Planning
11.5 Infertility
11.6 Healthy Pregnancy
11.7 Maternal Mortality and Disability
11.8 Neonatal Health
11.9 Gynecologic Health
11.10 Men’s Reproductive Health
11.11 Sexual Minority Health
References
Chapter 12 Nutrition
12.1 Nutrition and Global Health
12.2 Macronutrients
12.3 Protein-Energy Malnutrition
12.4 Food Security and Food Systems
12.5 Micronutrients
12.6 Iodine Deficiency Disorders
12.7 Vitamin A Deficiency
12.8 Iron Deficiency Anemia
12.9 Other Micronutrient Deficiencies
12.10 Breastfeeding
12.11 Overweight and Obesity
12.12 Food Safety
References
Chapter 13 Cancer
13.1 Cancer and Global Health
13.2 Cancer Biology
13.3 Cancer Epidemiology
13.4 Cancer Risk Factors and Prevention
13.5 Cancer Screening and Diagnosis
13.6 Cancer Treatment
13.7 Lung Cancer
13.8 Breast Cancer and Cervical Cancer
13.9 Prostate Cancer
13.10 Liver Cancer
13.11 Esophageal, Stomach, and Colorectal Cancers
13.12 Other Cancers
References
Chapter 14 Cardiovascular Diseases
14.1 Cardiovascular Disease and Global Health
14.2 Ischemic Heart Disease
14.3 Cerebrovascular Disease (Strokes)
14.4 Hypertension
14.5 Other Cardiovascular Diseases
References
Chapter 15 Other Noncommunicable Diseases
15.1 The Epidemiologic Transition and Global Health
15.2 NCDs and Behavior Change
15.3 Chronic Respiratory Diseases
15.4 Tobacco Control
15.5 Diabetes
15.6 Chronic Kidney Disease
15.7 Liver and Digestive Diseases
15.8 Neurological Disorders
15.9 Genetic Blood Disorders
15.10 Musculoskeletal Disorders
15.11 Sensory Disorders
15.12 Skin Diseases
15.13 Dental and Oral Health
References
Chapter 16 Mental Health
16.1 Mental Health and Global Health
16.2 Schizophrenia
16.3 Bipolar Disorder
16.4 Depressive Disorders
16.5 Anxiety Disorders
16.6 Alcohol and Drug Use Disorders
16.7 Other Mental Health Disorders
16.8 Suicide
16.9 Autism and Neurodevelopmental Disorders
16.10 Dementia and Neurocognitive Disorders
16.11 Mental Health Care
References
Chapter 17 Injuries
17.1 Injuries and Global Health
17.2 Transport Injuries
17.3 Falls
17.4 Drowning
17.5 Burns
17.6 Other Unintentional Injuries
17.7 Intentional Injuries
17.8 Interpersonal Violence
17.9 Gender-Based Violence
References
Chapter 18 Promoting Neonatal, Infant, Child, and Adolescent Health
18.1 Progress in Child Survival
18.2 Improving Neonatal Survival
18.3 Promoting Infant and Child Health
18.4 Promoting Early Childhood Development
18.5 Children with Special Needs
18.6 Health Promotion for Older Children
18.7 Health Promotion for Adolescents
References
Chapter 19 Promoting Healthy Adulthood and Aging
19.1 Aging and Global Health
19.2 Health Promotion in Early and Middle Adulthood
19.3 Health Promotion for Older Adults
19.4 Caring for Aging Populations
19.5 Health Promotion Across the Life Span
References
Chapter 20 Global Health Careers
20.1 Career Pathways in Global Health
20.2 Global Health Education
20.3 Experiential Learning in Global Health
20.4 Global Health Matters
References
Glossary
Index

Citation preview

THIRD EDITION

INTRODUCTION TO

GLOBAL HEALTH Kathryn H. Jacobsen, MPH, PhD George Mason University Fairfax, Virginia

World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2019 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Introduction to Global Health, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. 12396-8

Production Credits

VP, Product Management: David D. Cella Director of Product Management: Michael Brown Product Specialist: Carter McAlister Production Manager: Carolyn Rogers Pershouse Director of Vendor Management: Amy Rose Vendor Manager: Molly Hogue Senior Marketing Manager: Sophie Fleck Teague Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: codeMantra U.S. LLC

Library of Congress Cataloging-in-Publication Data

Project Management: codeMantra U.S. LLC Cover Design: Scott Moden Director of Rights & Media: Joanna Gallant Rights & Media Specialist: Robert Boder Media Development Editor: Shannon Sheehan Cover Image (Title Page, Chapter Opener): © Xinzheng. All Rights Reserved/Moment/Getty Printing and Binding: LSC Communications Cover Printing: LSC Communications

Names: Jacobsen, Kathryn H., author. Title: Introduction to global health / Kathryn H. Jacobsen. Description: Third edition. | Burlington, MA: Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017044502 | ISBN 9781284123890 (paperback: alk. paper) Subjects: | MESH: Global Health | Communicable Diseases | Health Promotion | Social Determinants of Health | Health Transition Classification: LCC RA441 | NLM WA 530.1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2017044502 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1

Contents

© Xinzheng. All Rights Reserved/Moment/Getty

Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

3.8  Governance and Politics. . . . . . . . . . . . . . . . . . . . . 61

New to This Edition. . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

Chapter 4 Environmental Determinants of Health. . . . . . . . . . . . . . . . . . . 65

Chapter 1 Global Health Transitions. . . . . . . 1

4.1  Environmental Health and the SDGs. . . . . . . . . 65

1.1  Defining Global Health. . . . . . . . . . . . . . . . . . . . . . . 1

4.2  Water, Sanitation, and Hygiene . . . . . . . . . . . . . . 67

1.2  Health Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . 3

4.3  Energy and Air Quality. . . . . . . . . . . . . . . . . . . . . . . 75

1.3  Prevention Science. . . . . . . . . . . . . . . . . . . . . . . . . . . 7

4.4  Occupational and Industrial Health. . . . . . . . . . 81

1.4  Health Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4.5 Urbanization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

1.5  World Regions and Featured Countries . . . . . . 12

4.6 Sustainability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

1.6  Global Health Security. . . . . . . . . . . . . . . . . . . . . . . 17

4.7  Climate Change and Health . . . . . . . . . . . . . . . . . 92

1.7  Globalization and Health: Shared Futures. . . . 18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Chapter 2 Global Health Priorities. . . . . . 21

Chapter 5 Health and Humans Rights . . . 98 5.1  Health and Human Rights. . . . . . . . . . . . . . . . . . . 98

2.1  Global Health Achievements . . . . . . . . . . . . . . . . 21

5.2  Access to Basic Human Needs. . . . . . . . . . . . . . 101

2.2  Prioritization Strategies. . . . . . . . . . . . . . . . . . . . . . 23

5.3  Access to Health Services. . . . . . . . . . . . . . . . . . . 103

2.3  Health Metrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

5.4  Access to Medicines. . . . . . . . . . . . . . . . . . . . . . . . 106

2.4  Millennium Development Goals. . . . . . . . . . . . . 34

5.5  Health and Natural Disasters. . . . . . . . . . . . . . . . 108

2.5  Sustainable Development Goals. . . . . . . . . . . . . 36

5.6  Conflict and War. . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

5.7 Bioterrorism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Chapter 3 Socioeconomic Determinants of Health. . . . . . . . . . . . . . . . . . . 42 3.1  Health Disparities and the SDGs. . . . . . . . . . . . . 42

5.8  Health in Prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 5.9  People with Disabilities. . . . . . . . . . . . . . . . . . . . . 119 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

3.2 Economics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Chapter 6 Global Health Financing. . . . . 126

3.3 Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

6.1  Personal and Public Health. . . . . . . . . . . . . . . . . 126

3.4 Gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

6.2  Health Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

3.5 Employment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

6.3  Paying for Personal Health. . . . . . . . . . . . . . . . . . 131

3.6  Minority Populations. . . . . . . . . . . . . . . . . . . . . . . . 57

6.4  Health Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . 133

3.7  Migrant and Refugee Health. . . . . . . . . . . . . . . . . 59

6.5  Paying for Global Health Interventions. . . . . . 135 iii

iv

Contents

6.6  Official Development Assistance. . . . . . . . . . . . 136

9.4 Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

6.7  Multilateral Aid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

9.5  Other Respiratory Infections. . . . . . . . . . . . . . . . 206

6.8  Foundations and Corporate Donations. . . . . 140

9.6 Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

6.9  Personal Donations. . . . . . . . . . . . . . . . . . . . . . . . . 142

9.7 Immunization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

9.8  Vaccine-Preventable Infections. . . . . . . . . . . . . 212

Chapter 7 Global Health Implementation . . . . . . . . . . . 148 7.1  Global Health Interventions . . . . . . . . . . . . . . . . 148 7.2  Local and National Governments. . . . . . . . . . . 150 7.3  International Cooperation. . . . . . . . . . . . . . . . . . 151

9.9  Viral Hepatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 9.10 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Chapter 10 Malaria and Neglected Tropical Diseases. . . . . . . . . . 224

7.4  The World Health Organization and the United Nations�����������������������������������������153

10.1  Malaria, NTDs, and Global Health. . . . . . . . . . 224

7.5  International Health Regulations. . . . . . . . . . . . 156

10.3 Malaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

7.6  Global Partnerships. . . . . . . . . . . . . . . . . . . . . . . . . 158

10.4  Malaria Interventions. . . . . . . . . . . . . . . . . . . . . . 229

7.7  The Nonprofit Sector. . . . . . . . . . . . . . . . . . . . . . . 159

10.5  Dengue and Other Arboviruses . . . . . . . . . . . 233

7.8  The Corporate Sector. . . . . . . . . . . . . . . . . . . . . . . 161

10.6  Chagas Disease and Trypanosomiasis. . . . . . 236

7.9  Research and the Academic Sector. . . . . . . . . 162

10.7 Leishmaniasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

7.10  Measuring Impact. . . . . . . . . . . . . . . . . . . . . . . . . 163

10.8 Schistosomiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . 237

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

10.9  Lymphatic Filariasis. . . . . . . . . . . . . . . . . . . . . . . . 238

Chapter 8 HIV/AIDS and Tuberculosis. . . 167

10.2  Parasites: Protozoa and Helminths. . . . . . . . . 227

10.10 Onchocerciasis. . . . . . . . . . . . . . . . . . . . . . . . . . . 239 10.11  Leprosy, Buruli Ulcer, and Trachoma. . . . . . 240

8.1  HIV/AIDS, TB, and Global Health. . . . . . . . . . . . . 167

10.12 Rabies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

8.2  Viruses, Bacteria, and Fungi. . . . . . . . . . . . . . . . . 168

10.13  Soil-Transmitted Helminths . . . . . . . . . . . . . . 242

8.3  HIV and AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

10.14  Other Neglected Tropical Diseases. . . . . . . 244

8.4  HIV/AIDS Epidemiology . . . . . . . . . . . . . . . . . . . . 173

10.15 Eradication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

8.5  HIV Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . 179

10.16  Emerging Infectious Diseases. . . . . . . . . . . . 250

8.6  Other Sexually Transmitted Infections. . . . . . . 183

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

8.7 Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 8.8  TB Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Chapter 11 Reproductive Health . . . . . . 257

8.9  Antimicrobial Resistance. . . . . . . . . . . . . . . . . . . 189

11.1  Reproductive Health and Global Health . . . 257

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

11.2  The Fertility Transition. . . . . . . . . . . . . . . . . . . . . 259

Chapter 9 Diarrheal, Respiratory, and Other Common Infections. . . . . . . . . . . . . . . . . 195

11.3  Population Planning. . . . . . . . . . . . . . . . . . . . . . 263 11.4  Family Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . 264 11.5  Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 11.6  Healthy Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . 269

9.1  Infectious Diseases and Global Health . . . . . . 195

11.7  Maternal Mortality and Disability. . . . . . . . . . 272

9.2  Diarrheal Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . 198

11.8  Neonatal Health. . . . . . . . . . . . . . . . . . . . . . . . . . . 275

9.3  Diarrhea Interventions. . . . . . . . . . . . . . . . . . . . . . 200

11.9  Gynecologic Health. . . . . . . . . . . . . . . . . . . . . . . 279

Contents

v

11.10  Men’s Reproductive Health. . . . . . . . . . . . . . . 279

14.4  Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

11.11  Sexual Minority Health. . . . . . . . . . . . . . . . . . . 280

14.5  Other Cardiovascular Diseases. . . . . . . . . . . . . 348

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

Chapter 12 Nutrition . . . . . . . . . . . . . . . . 285

Chapter 15 Other Noncommunicable Diseases. . . . . . . . . . . . . . . . . 351

12.1  Nutrition and Global Health. . . . . . . . . . . . . . . 285 12.2  Macronutrients. . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 12.3  Protein-Energy Malnutrition. . . . . . . . . . . . . . . 288

15.1 The Epidemiologic Transition and Global Health�������������������������������������������������351

12.4  Food Security and Food Systems. . . . . . . . . . 293

15.2  NCDs and Behavior Change. . . . . . . . . . . . . . . 355

12.5  Micronutrients. . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

15.3  Chronic Respiratory Diseases. . . . . . . . . . . . . . 358

12.6  Iodine Deficiency Disorders . . . . . . . . . . . . . . . 297

15.4  Tobacco Control. . . . . . . . . . . . . . . . . . . . . . . . . . . 360

12.7  Vitamin A Deficiency. . . . . . . . . . . . . . . . . . . . . . 297

15.5  Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

12.8  Iron Deficiency Anemia . . . . . . . . . . . . . . . . . . . 298

15.6  Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . 366

12.9  Other Micronutrient Deficiencies. . . . . . . . . . 300

15.7  Liver and Digestive Diseases. . . . . . . . . . . . . . . 367

12.10  Breastfeeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

15.8  Neurological Disorders. . . . . . . . . . . . . . . . . . . . 368

12.11  Overweight and Obesity. . . . . . . . . . . . . . . . . 304

15.9  Genetic Blood Disorders. . . . . . . . . . . . . . . . . . . 369

12.12  Food Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

15.10  Musculoskeletal Disorders. . . . . . . . . . . . . . . . 371

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

15.11  Sensory Disorders. . . . . . . . . . . . . . . . . . . . . . . . 372

Chapter 13 Cancer. . . . . . . . . . . . . . . . . . . 315 13.1  Cancer and Global Health. . . . . . . . . . . . . . . . . 315 13.2  Cancer Biology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 316

15.12  Skin Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374 15.13  Dental and Oral Health. . . . . . . . . . . . . . . . . . . 374 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

13.3  Cancer Epidemiology . . . . . . . . . . . . . . . . . . . . . 316

Chapter 16 Mental Health. . . . . . . . . . . . 381

13.4  Cancer Risk Factors and Prevention. . . . . . . . 320

16.1  Mental Health and Global Health. . . . . . . . . . 381

13.5  Cancer Screening and Diagnosis . . . . . . . . . . 324

16.2  Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382

13.6  Cancer Treatment. . . . . . . . . . . . . . . . . . . . . . . . . 326

16.3  Bipolar Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . 383

13.7  Lung Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328

16.4  Depressive Disorders. . . . . . . . . . . . . . . . . . . . . . 383

13.8  Breast Cancer and Cervical Cancer. . . . . . . . . 328

16.5  Anxiety Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . 385

13.9  Prostate Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . 332

16.6  Alcohol and Drug Use Disorders. . . . . . . . . . . 385

13.10  Liver Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

16.7  Other Mental Health Disorders. . . . . . . . . . . . 387

13.11  Esophageal, Stomach, and Colorectal Cancers���������������������������������������������333

16.8  Suicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

13.12  Other Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

16.9 Autism and Neurodevelopmental Disorders�������������������������������������������������������������������390

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

16.10  Dementia and Neurocognitive Disorders.391

Chapter 14 Cardiovascular Diseases. . . . 338 14.1  Cardiovascular Disease and Global Health. 338

16.11  Mental Health Care . . . . . . . . . . . . . . . . . . . . . . 391 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392

14.2  Ischemic Heart Disease. . . . . . . . . . . . . . . . . . . . 342

Chapter 17 Injuries. . . . . . . . . . . . . . . . . . 396

14.3  Cerebrovascular Disease (Strokes). . . . . . . . . 344

17.1  Injuries and Global Health. . . . . . . . . . . . . . . . . 396

vi

Contents

17.2  Transport Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . 400 17.3  Falls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402 17.4  Drowning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 17.5  Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404

Chapter 19 Promoting Healthy Adulthood and Aging. . . . . . 425 19.1  Aging and Global Health. . . . . . . . . . . . . . . . . . 425

17.6  Other Unintentional Injuries. . . . . . . . . . . . . . . 405

19.2 Health Promotion in Early and Middle Adulthood���������������������������������������428

17.7  Intentional Injuries. . . . . . . . . . . . . . . . . . . . . . . . 405

19.3  Health Promotion for Older Adults. . . . . . . . . 430

17.8  Interpersonal Violence . . . . . . . . . . . . . . . . . . . . 406

19.4  Caring for Aging Populations. . . . . . . . . . . . . . 431

17.9  Gender-Based Violence. . . . . . . . . . . . . . . . . . . . 407

19.5 Health Promotion Across the Life Span�����������������������������������������������������������434

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408

Chapter 18 Promoting Neonatal, Infant, Child, and Adolescent Health. . . . . . . . . 410

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434

Chapter 20 Global Health Careers. . . . . . 436 20.1  Career Pathways in Global Health. . . . . . . . . . 436

18.1  Progress in Child Survival. . . . . . . . . . . . . . . . . . 410

20.2  Global Health Education . . . . . . . . . . . . . . . . . . 437

18.2  Improving Neonatal Survival. . . . . . . . . . . . . . 415

20.3 Experiential Learning in Global Health�����������������������������������������������������439

18.3  Promoting Infant and Child Health. . . . . . . . 417 18.4  Promoting Early Childhood Development. 419 18.5  Children with Special Needs. . . . . . . . . . . . . . . 419 18.6  Health Promotion for Older Children . . . . . . 420

20.4 Global Health Matters. . . . . . . . . . . . . . . . . . . . . 440 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442

18.7  Health Promotion for Adolescents. . . . . . . . . 421

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468

Preface

T

he first and second editions of Introduction to Global Health were written during the Millennium Development Goals (MDG) era of global health. The MDGs spelled out an ambitious plan for significantly reducing global poverty between 2000 and 2015. They were wildly successful. The number of people living on less than $1 per day dropped substantially during the first 15 years of the 21st century. As a growing number of global health partnerships set agendas for change and financed action plans, significant progress was made toward alleviating hunger, preventing maternal and child mortality, and controlling HIV/AIDS and malaria. The next generation of global goals—the Sustainable Development Goals (SDGs)—were launched at the end of 2015. They spell out 17 goals for enhancing human flourishing by 2030, including targets related to poverty reduction, hunger, health, education, gender equality, clean water and sanitation, affordable and clean energy, decent work, infrastructure and technology development, human rights, sustainable urbanization, responsible production and consumption, climate and environment, peace, and governance. The SDGs seek to promote prosperity while upholding human rights, protecting the planet, and fostering peace and security. All of the goals are interdependent, and all are inextricably tied to health. Improvements in any of the 17 areas will yield benefits for population health, and improvements in public health will enable other SDGs to be achieved. Most of the MDGs were targeted at improving quality of life among the world’s poorest people. The SDGs retain those aims but add a lengthy list of objectives that apply to countries

© Xinzheng. All Rights Reserved/Moment/Getty

across the income spectrum. For example, the SDGs include targets for preventing new hepatitis B virus infections; reducing the number of adults who die from cardiovascular diseases, cancers, and other noncommunicable diseases before their 70th birthdays; reducing the suicide mortality rate; increasing access to treatment for substance use disorders; and reducing deaths from road traffic injuries and violence. These conditions affect people in every country, and all countries have the opportunity under the SDGs to track their progress toward improving health metrics related to these concerns. This third edition of Introduction to Global Health is a book for the SDG era. The socioeconomic and environmental determinants of health are presented in the context of the SDGs. The shifting landscape for financing and implementing global health initiatives is described in expanded chapters on payers and players. Chapters on infectious diseases, reproductive health, and nutrition are complemented by new chapters on noncommunicable diseases, mental health, and injuries. The similarities and differences in the conditions that cause illness and death in featured countries representing diverse world regions and income levels are illustrated with estimates from the Global Burden of Disease (GBD) project, which now produces annually updated profiles of health status in every country. (Disclosure: the author is a GBD collaborator.) The global health agenda has expanded to cover all of the world’s people, and this book provides a positive, forward-looking perspective on the numerous actions that are helping promote the health, well-being, and security of people across the lifespan and across the globe. vii

New to This Edition The third edition of Introduction to Global Health has been significantly expanded to include more comprehensive coverage of the full spectrum of topics that now constitute part of the global health agenda. Chapter 1 presents a new model for identifying global health issues—one that incorporates populations, action, cooperation, equity, and security—and it introduces the key concepts of prevention science, health transitions theory, globalization, and global health security. Chapter 2 introduces the new Sustainable Development Goals (SDGs) that will guide international development efforts through 2030 and describes the most commonly used global health metrics. Chapters 3 and 4 use the SDGs as a framework for exploring the social and environmental determinants of health. Chapter 3 describes the connections between health and economics, education, gender, employment, culture, migration, and governance. Chapter 4 examines the links between health and water, sanitation, energy, air quality, occupational and industrial health, urbanization, sustainability, and climate change. Chapter 5 uses the SDGs and the Universal Declaration of Human Rights to highlight some of the major ethical issues in global health, including questions about the right to have access to healthcare services and medicines, humanitarian responsibilities after natural disasters and during times of conflict, and the rights of people in prison, people with disabilities, and other special populations. viii

© Xinzheng. All Rights Reserved/Moment/Getty

Chapter 6 is a new chapter that describes the health system models used in various countries and explains the funding mechanisms used to pay for global health activities. Chapter 7 features the diversity of entities involved in implementing and evaluating global health interventions, including governmental and intergovernmental agencies, nonprofit organizations, and for-profit corporations. Chapters 8 through 17 present the health conditions that account for the greatest burden of disease globally. Each chapter begins with a section that explains why the featured topic is considered to be a global health issue, and each chapter emphasizes the interventions that can reduce the impact of adverse health conditions on individuals and populations. Health metrics from the Global Burden of Disease (GBD) collaboration are used to illustrate the populations affected by each condition. Chapter 8 describes the global threats posed by HIV/AIDS, tuberculosis, and antimicrobial resistance. Chapter 9 discusses the heavy toll that child mortality from diarrheal diseases and pneumonia takes on low-income countries and describes the tools that are available to contain outbreaks of influenza and other vaccine-preventable infections. Chapter 10 describes the burden from malaria and neglected tropical diseases in low-income countries and the global threats associated with emerging infectious diseases. Chapter 11 highlights a diversity of reproductive and sexual health issues, including family planning, infertility, pregnancy, maternal mortality, neonatal health, men’s health, and sexual minority

New to This Edition

health. Chapter 12 describes the nutrition transition and the challenges associated with undernutrition, overnutrition, and food safety. A series of new chapters describe the opportunities for global health initiatives to address the noncommunicable diseases (NCDs), mental health disorders, and injuries that are among the leading causes of death worldwide. Chapter 13 focuses on cancer, Chapter 14 focuses on cardiovascular disease, and Chapter 15 focuses on chronic respiratory diseases and diabetes. The principles of behavior change, tobacco control, and other methods for prevention and management of NCDs are highlighted. Chapter 16 describes the diversity of mental health conditions that contribute to global disease burden and emphasizes the need for greater access to mental health services. Chapter 17 discusses injury prevention and control methods. Two chapters synthesize the core messages of the book through the lens of health promotion across the lifespan. Chapter 18 presents the major improvements in neonatal, infant, child, and adolescent health that were

ix

achieved under the MDGs and the opportunities for continued progress under the SDGs. Chapter 19 describes the emerging challenges associated with aging populations and the opportunities for promoting healthy adulthood and aging. Chapter 20 is a new chapter that describes the links between diverse educational and career pathways and global health, and emphasizes the opportunities for everyone to be involved in making communities and the world a healthier place for current and future generations. More than 350 figures and tables highlight key material, and nearly all of these are new for the third edition. All of the statistics in the book have been updated. Data from eight of the world’s largest countries, which collectively are home to half of the world’s people, are used to illustrate the patterns of health status in high-income, middle-income, and low-income countries: Brazil, China, Ethiopia, Germany, India, Iran, Nigeria, and the United States. A new glossary provides definitions for more than 780 key terms in global health.

About the Author

© Xinzheng. All Rights Reserved/Moment/Getty

Kathryn H. Jacobsen, MPH, PhD, is professor of epidemiology and global health at George Mason University. She is the author of more than 150 scientific articles as well as Introduction to Health Research Methods: A Practical Guide, also published by Jones & Bartlett Learning. She is also a contributor to the Global ­Burden of Disease project and frequently ­provides commentary for print and television media.

x

© Xinzheng. All Rights Reserved/Moment/Getty

CHAPTER 1

Global Health Transitions Global health is a multidisciplinary, multisectoral field in which diverse partners from around the world act together to improve population and environmental health. Scientific advances during the last century have reduced infant and child death rates, increased the number of infectious diseases that can be prevented or cured, and provided new tools for managing the chronic diseases associated with aging. Global health activities can also be effective for promoting security, stimulating economic growth, fostering justice, and achieving other shared goals.

▸▸

1.1  Defining Global Health

Health is often defined as the absence of disease or injury, but this is an incomplete explanation because the focus is on what health is not, rather than on what health is. Some definitions of health try to focus on the essence of health by emphasizing health as the ability to conduct normal daily activities. But that type of statement is also limited because the definition of “normal” varies from person to person. For example, some people assume that it is normal for an older person to have limited mobility and forgetfulness, but that is not true. Many older people are very active and mentally sharp, and many of those who have joint pain or memory loss could be helped by therapy and medication. Similarly, in many parts of the world, parents think it is normal for their children to have intestinal worms. This belief is also not true, and untreated worm infections significantly reduce the health, growth, and

school performance of millions of children worldwide. A more comprehensive definition of health addresses both physical and mental health as well as the presence of a social system that facilitates health. The Constitution of the World Health Organization (WHO), written in 1948, defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” This definition recognizes that health is not just a function of biology. Health stems from biology, psychology, sociology, and a host of other factors. Although there is almost no one in the world today who would be classified as having “complete” health according to the WHO statement,1 this definition provides a target for medical and public health systems as they work together to promote the improved health status of individuals and communities. An ideal health trajectory begins with a consenting adult becoming pregnant and that pregnancy leading to an uneventful full-term delivery of a healthy newborn. After birth, 1

2

Chapter 1 Global Health Transitions

the ideal health trajectory continues with that healthy infant growing into adulthood without experiencing serious infections, injuries, or illnesses, and that adult remaining healthy and active for many decades. Because everyone eventually dies, the ideal health trajectory ends in very old age with a gentle death that is not preceded by months or years of disability and pain. However, few people achieve this ideal pathway (FIGURE 1–1A). In very low-income communities, a large proportion of children are born with low birthweight and struggle with repeated bouts of infectious diseases like pneumonia and malaria, and many young women die in childbirth (FIGURE 1–1B). No matter where a person lives, a combination of happenstance and health behaviors may reduce health status at various time periods over the life span. A healthy child may develop permanent physical impairments due to a serious car crash in adolescence, then have reduced health status from alcohol abuse in middle adulthood, and die from a heart attack before reaching retirement age (FIGURE 1–1C). Even when people live to be very old, they usually experience a

gradual decline in function and loss of independence prior to dying (FIGURE 1–1D). A diversity of medical, behavioral, social, economic, environmental, and other interventions and changes can help people make progress toward long, healthy life trajectories. Some of these actions are taken by individuals to improve their own health status, some are communal activities by families and neighborhoods, and some are largescale initiatives that take place on a national or international scale. Global health refers to the collaborative actions taken to identify and address transnational concerns about the exposures and diseases that adversely affect human populations. There are many different lenses that are used to identify global health issues (FIGURE 1–2). Epidemiologists and health economists may evaluate global health metrics and select the conditions that cause the majority of deaths, disability, and lost productivity worldwide. Physicians, nurses, and other clinical practitioners may see suffering that could easily be prevented or relieved and feel compelled to find ways to scale up the delivery of cost-effective solutions

ideal

health status

health status

ideal

death

death birth

very old age

A (Ideal Health Trajectory)

birth

very old age

birth

very old age

B ideal

health status

health status

ideal

death

death birth

very old age

C

FIGURE 1–1  Examples of health trajectories.

D

1.2  Health Interventions

Populations

A focus on the exposures and diseases that cause the greatest public health burden and affect large numbers of people in diverse geographic regions

Action

A focus on effective, lowcost interventions that prevent illness and injury, diagnose and treat diseases, and alleviate suffering

Cooperation

A focus on the health concerns that must be addressed through worldwide efforts to share knowledge, tools, and resources

Equity

A focus on helping the global poor and addressing social, environmental, and health inequalities

Security

A focus on addressing the health issues most likely to contribute to political and economic instability and conflict

FIGURE 1–2  PACES: Defining global health.

to people in need, no matter where those people live. Environmental health scientists may observe how quickly some pathogens and toxins cross international borders and recognize that international partnerships are necessary in order to mitigate those threats to health. Health promoters and others whose work is guided by a social justice perspective may focus on calling attention to the health needs of the most vulnerable people around the world. Security experts may zero in on the factors that contribute to instability and conflict. All of these global health lenses—ones focused on populations, action, cooperation, equity, and security (PACES)— emphasize transnational health issues, but

3

different global health priorities will emerge when different lenses are applied (FIGURE 1–3). These varied perspectives are why so many different environmental concerns, a broad range of diseases, and a diversity of special populations have been targeted by global health initiatives.

▸▸

1.2  Health Interventions

Etiology is the study of the causes of disease, including both intrinsic (internal) causes, such as genetics and psychological factors, and extrinsic (external) causes, such as infectious disease and environmental exposures. A person’s health status at a given age is a function of his or her experiences throughout the life course.2 These biological, behavioral, and other exposures occur in particular natural and built environments, and they are also a function of a broad set of social, political, cultural, economic, occupational, and other ­factors.3 The diversity of contributors to disease means that a considerable diversity of changes can improve health. Humans have long recognized the environment’s role in disease etiology. For many centuries before microscopes allowed people to observe bacteria, communities recognized that some illnesses were linked to environmental exposures, and they took care to dispose of human waste, protect water sources, and bury the carcasses of diseased animals. During most of the 19th century, the term miasma was used to describe the pungent odors of poorly managed waste, and the prevailing theory of disease causation in Western countries was that epidemics were spontaneously generated in places with poor sanitation.4 When cholera outbreaks occurred in England in the mid-1800s, investigators found a higher infection rate in places of low altitude, especially places near marshes that had an abundance of foul-smelling gases, and they blamed the spread of cholera on contact with those offensive gases.5 This was

4

Chapter 1 Global Health Transitions

Lens

Sample Priority

Sample Priority

Populations

Cardiovascular disease (CVD)

CVD is the leading cause of adult mortality worldwide.

Drinking water

Unsafe drinking water causes billions of cases of severe diarrhea annually.

Action

Hunger

There is enough food in the world to spare children from the lifelong consequences of not having access to adequate nutrition during their early years of development.

HIV

HIV medications can extend the lives of infected individuals by many years or even decades.

Cooperation

Air pollution

Air pollution generated by one country can cause adverse health effects for its neighbors.

Drugresistant infections

One country with poor regulations for antibiotic use can put the whole world at risk.

Equity

Neglected tropical diseases

The world’s poorest children are disabled and disfigured by parasitic diseases that do not affect children who happen to have been born in higherincome places.

Mental health

People with mental health disorders in every country face stigma that may exclude them from full participation in society.

Security

Violence

The violence in conflict areas can spill over into new locations and create refugee crises.

Emerging infectious diseases

Outbreaks of deadly infectious diseases threaten public safety and can cause social, economic, and political instability.

FIGURE 1–3  PACES: Examples of global health priorities.

a reasonable conclusion because the people who lived in the gassy, marshy areas were the same people who drank the bacterium-­infected water that was the true cause of the outbreak. Public health efforts in the 19th century focused primarily on environmental sanitation, with special attention aimed at reducing epidemics thought to be associated with urban

crowding and its associated grime.6 Although outbreaks are no longer blamed on miasmas, good hygiene (like frequent handwashing) and the avoidance of known environmental hazards remain very important for preventing infections and injuries. By the middle of the 20th century, most medical scientists had shifted their efforts

1.2  Health Interventions

from the identification of social and environmental risk factors for disease to the identification of specific infectious agents and genes.7 But even with the emphasis on immunology and genetics, one of the biggest public health breakthroughs in the 20th century was a series of studies published in the 1950s that confirmed that cigarette smoking was a major cause of lung cancer, emphysema, and cardiovascular disease.8 Later studies showed that exposure to secondhand smoke was an additional risk factor for lung disease.9 Today, health scientists and clinicians agree that there are many social and behavioral, environmental, and biological contributors to disease. This means that there are diverse actions that can improve health status. The particular set of interventions recommended for global health concerns tends to reflect the disciplinary perspectives of the people designing and implementing the interventions.10 Two of the most prominent voices in global health in the 21st century are medicine and public health. Medicine focuses on preventing, diagnosing, and treating health problems in individuals and families. For thousands of years, various types of health practitioners in cultures across the globe have cared for people with health concerns, including herbalists adept at treating fevers, midwives skilled in delivering babies, and numerous other people equipped to provide physical and spiritual comfort to people with various ailments. As modern medical science has developed, clinical professionals like physicians, surgeons, nurses, dentists, psychologists, and physical therapists have developed highly specialized methods for caring for patients. Examples of common interventions in the medical field include antibiotics to treat infections, medications to manage chronic diseases (such as insulin for people with diabetes and inhaled bronchodilators for people with asthma), counseling to address mental health concerns, surgery to correct traumatic injuries, and physical therapy to restore function after an injury.

5

Public health focuses on promoting health and preventing illnesses, injuries, and early deaths at the population level by identifying and mitigating environmental hazards, promoting healthy behaviors, ensuring access to essential health services, and taking other actions to protect the health, safety, and well-being of groups of people (FIGURE 1–4).11 Modern public health comprises a diversity of subdisciplines. Environmental health is the study of the connections between human 1

Monitor health status to identify community health problems.

2

Diagnose and investigate health problems and health hazards in the community.

3

Inform, educate, and empower people about health issues.

4

Mobilize community partnerships to identify and solve health problems.

5

Develop policies and plans that support individual and community health efforts.

6

Enforce laws and regulations that protect health and ensure safety.

7

Link people to needed personal health services and ensure the provision of health care when otherwise unavailable.

8

Ensure a competent public health and personal healthcare workforce.

9

Evaluate effectiveness, accessibility, and quality of personal and populationbased health services.

10

Research for new insights and innovative solutions to health problems.

FIGURE 1–4  Essential public health services. Reproduced from The public health system & the 10 essential public health services. Centers for Disease Control and Prevention website https://www .cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices .html. Updated September 20, 2017.

6

Chapter 1 Global Health Transitions

health and environmental exposures, such as air quality, water quality, solid and hazardous waste, unsafe food, vermin and pathogen-­ transmitting insects, radiation, noise, and residential and industrial hazards. E ­ pidemiology is the study of the distribution of health problems in populations, the risk factors for developing those conditions, and the effectiveness of interventions to address these concerns. Biostatistics is the science of analyzing health data and interpreting the results so that they can be applied to solving public health problems. Health promotion is an applied social science that encourages individuals and communities to take steps to improve their own health. The Ottawa Charter for Health Promotion was an international agreement sponsored by the WHO and approved at a conference in Canada in 1986 that identified the core health promotion actions as including healthy public policies, supportive environments, strong communities, skilled personnel, and expanded access to preventive health services.12 There are also specialists in health policy and management, public health administration, health communication, maternal and child health, public health nutrition, health economics, and other public health fields. Examples of common public health interventions include policies that ensure that food and drinking water are safe, vaccination campaigns that prevent widespread outbreaks of infectious diseases, health education campaigns Individuals

Families

that promote active lifestyles for people of all ages, and school nutrition programs that ensure that children have access to the nutritious food they need to grow and learn. The lines between medicine and public health are blurry (FIGURE 1–5). Medicine tends to focus on the clinical care of individuals, while public health has a focus on larger populations. Public health usually emphasizes the prevention of health problems while medicine has more of a focus on treating the existing problems. But many people trained in clinical fields work in population health and provide preventive services (including public health nurses, physicians specializing in community medicine and preventive medicine, and others), and many people trained in public health are dedicated to increasing access to treatment for individuals with critical health issues. Medical research informs the design of public health interventions, and the information generated from public health research helps clinicians to make differential diagnoses, prescribe appropriate therapies, and encourage healthy lifestyles for their patients in addition to helping communities set their own public health priorities and design and evaluate ­evidence-based programs to address these issues. In global health, an intervention is a strategic action intended to improve individual and population health status. Interventions take many different forms: detection and treatment of physical and mental health

Communities

Medicine

States/provinces

Nations

Public health

Prevention

Treatment

Public health

Medicine

FIGURE 1–5  Comparing medicine and public health.

1.3  Prevention Science

conditions, counseling and social marketing to promote healthier behaviors, development and enforcement of health policies, and numerous other actions.13 ­Interventions targeted at any level from the individual to the community, the nation, and the world can be effective at improving personal and public health. For example, nutrition support programs for pregnant and breastfeeding women can reduce the risk of low birthweight and malnutrition in infants, the use of antibiotics to treat childhood pneumonia soon after the onset of a cough can prevent life-threatening illness, the availability of skilled birth attendants can prevent women from dying during childbirth, and numerous other interventions during adulthood, such as injury prevention activities, mental health care, and lifestyle changes that reduce the risk of heart attacks, can improve both quality of life and the number of years lived (FIGURE  1–6). Together, these interventions can have a strong positive impact on an individual’s health, allowing a person who might otherwise have been in poor health in childhood and died young to instead have a healthy childhood and live to old age. When these interventions reach millions of people, they make a huge difference in population health, happiness, and productivity. Because individual and community health status is the result of a complex mix of biological, socioeconomic, environmental, and other factors, the clinical disciplines and public

health cannot on their own accomplish global health goals. People working in a diversity of fields make important contributions to the conditions that promote or inhibit the health of individuals and communities. Social workers, spiritual advisors, teachers, sanitation workers, farmers, scientists and engineers, policymakers and lawyers, a variety of government officials, and many others all have a role to play in the big-picture interventions that enable health.

▸▸

1.3  Prevention Science

The adage that prevention is better than a cure expresses one of the foundational principles of global health. It is usually cheaper to spend relatively small amounts of money on interventions that keep people healthy across the life span than it is to spend relatively large amounts of money helping people recover from serious health problems (FIGURE 1–7). Severe health problems, long-term disabilities, and untimely deaths are expensive for the affected individuals and for their families, who must pay the direct costs of medical care as well as bear the direct and indirect costs of caregiving. Health problems are also costly for the communities and nations that lose the economic and other contributions the affected individuals would have made through work productivity, tax revenue, and service if they had lived longer, healthier lives. Prevention science is the process of

Baseline scenario

Health trajectory with interventions

ideal health status

ideal

nutritional support

death

antibiotics

skilled birth attendants

medical therapies

death birth

old age

7

birth

FIGURE 1–6  Examples of interventions that improve health trajectories across the life span.

old age

8

Chapter 1 Global Health Transitions

High cost interventions

Low cost interventions health status

clean education blood psychological water pressure counseling medicine

health status

ideal

ideal

rehabilitation after a lifethreatening infection

death

death birth

very old age

birth

rehabilitation after a stroke

very old age

FIGURE 1–7  Maintaining good health status through preventive interventions is less costly than paying for rehabilitation after health crises.

determining which preventive health interventions are effective in various populations, how successful the interventions are, and how well they can be scaled up for widespread implementation.14 There are three levels of prevention ­(FIGURE 1–8). When an effective intervention for preventing disease or promoting health has been identified, primary prevention actions can keep an adverse health event from ever occurring. Numerous global health initiatives focus on primary prevention. Some promote health behaviors, such as vaccinating children to protect them from measles and polio infections, exercising to protect against heart disease, avoiding tobacco to reduce the risk of lung disease, and using a seatbelt to reduce the risk of serious injuries during a motor vehicle collision. Some programs work to modify the health environment by increasing access to improved sanitation facilities to prevent diarrhea, spraying insecticides to kill the mosquitoes that spread infections, implementing clean delivery room practices to prevent infections of newborns and their mothers, and building roads that are safe for bicyclists and pedestrians. Others use policy changes to improve access to healthcare services, essential medications, and nutritious foods. The goal of secondary prevention is to detect health problems at an early stage when they have not yet caused significant damage to the body and can be treated more easily.

Secondary prevention interventions typically are targeted at people with early, asymptomatic (that is, not symptomatic) disease, so that health problems can be diagnosed before they become so severe that the affected individuals seek health services. There are numerous types of cancer screening tests that are forms of secondary prevention, such as mammography for breast cancer, Pap smears for cervical cancer, and colonoscopies that look for the polyps that are precursors to colorectal cancer. Other examples of screening tests include routine HIV tests, blood pressure checks in adults, and vision tests for children, all of which are intended to detect health issues in people who might otherwise remain unaware of the presence of these manageable health conditions for many years. The aim of tertiary prevention is to reduce impairment, minimize pain and suffering, and prevent death in people with symptomatic health problems. Examples of tertiary prevention include treating chronic diseases with medication, alleviating the pain of people with advanced cancers, and providing physical therapy and occupational therapy to people recovering from strokes. Given the three levels of prevention, there is almost always some intervention that could improve the health of those who are vulnerable to a particular disease or are already sick. Primary prevention is the preferred option when a cost-effective preventive intervention is available. When primary prevention is not

1.4  Health Transitions

Level Primary prevention

Secondary prevention

Tertiary prevention

Also Called…

Target Population

Prevention

People without disease

Early diagnosis

Treatment and rehabilitation

Goal

Examples

Prevent disease from ever occurring

■■

People with early, nonsymptomatic disease

Reduce the severity of disease and prevent disability and death

■■

People with symptomatic disease

Reduce impairment and minimize suffering

■■

■■

■■

■■

9

Vaccinating children to protect them from paralytic polio Giving vitamin A capsules to at-risk children to prevent blindness Checking blood pressure routinely to detect the onset of hypertension Screening with mammography to detect early-stage breast cancer Extracting teeth with severe decay in order to alleviate pain Providing physical therapy to people who have been injured in a vehicle collision in order to prevent longterm disability

FIGURE 1–8  Three levels of prevention: primary, secondary, and tertiary.

possible or health problems are already present, secondary prevention and tertiary prevention can improve longevity and quality of life.

▸▸

1.4  Health Transitions

The changing health profiles observed in high-income countries over the last century are strong evidence that large-scale health interventions are effective at improving health throughout the life course. One hundred years ago, most populations across the globe had similar health profiles: high birth rates, high death rates, short life expectancies, and a considerable number of diseases and deaths due to infections and undernutrition. During the 20th century, most high-income nations made a transition to a

lower birth rate, a lower death rate, longer life expectancies, and a higher burden from the chronic diseases often associated with overnutrition. For example, in the United States, the leading causes of death in 1800 and 1900 were pneumonia (including pneumonia caused by influenza), tuberculosis, and diarrhea, all of which are infectious diseases.15 By 1950, the death rate had dropped significantly, life expectancy had increased, and the most common causes of death had shifted to heart disease, cancer, and stroke, the same noncommunicable diseases that remain the most frequent causes of death in the United States today.16 These changes in population health status were due to a variety of factors, including new health technologies, such as new vaccines, new antibiotics, and new contraceptives, as well as improved sanitation,

10

Chapter 1 Global Health Transitions

better nutrition, increased education, and economic growth.17 A health transition is a shift in the health status of a population that usually occurs in conjunction with socioeconomic development. Over the last century, high-­ income countries have experienced a diversity of health transitions: decreases in fertility rates, changes in population size and age structures, substantial reductions in the risk of death from ­pregnancy-related conditions, shifts from hunger to obesity as a dominant nutritional concern, increases in health problems associated

with sedentary lifestyles, decreases in infectious diseases and corresponding increases in chronic diseases, reductions in infant and child mortality, and increases in life expectancy and the proportion of older adults in the population (FIGURE 1–9). Low-income countries have not experienced such dramatic changes. Because some countries have gone through these health transitions and other countries have not, there are now significant differences in health status in the ­highest-income and lowest-­income countries (FIGURE 1–10). A diversity of health statistics

Type of Transition

Pre-transition Populations

Post-transition Populations

Fertility transition

The typical woman gives birth to several children.

The typical woman gives birth to only one child or two children.

Demographic transition

The total population size may be increasing due to high birth rates.

The total population size may be shrinking because birth rates are so low.

Obstetric transition

Pregnancy-related conditions are a common cause of death in women of reproductive age.

The maternal mortality rate is very low.

Nutrition transition

Underweight is a major concern.

Obesity is a major concern.

Risk transition

Environmental exposures like unsafe drinking water and polluted indoor air are major contributors to disease.

Lifestyle factors like physical inactivity and tobacco use are major contributors to disease.

Epidemiologic transition

Infectious diseases in children are a significant burden to the population.

Chronic diseases in adults are the dominant health concern in the population.

Mortality transition

High death rates in children and reproductive-age adults mean that few people live to very old age.

Low mortality rates for children and reproductive-age adults allow many people to live to old age.

Aging transition

Children comprise the majority of the total population.

Older adults are a growing proportion of the population.

FIGURE 1–9  Examples of health transitions.

1.4  Health Transitions

Today, in Very LOW-Income Populations…

11

Today, in Very HIGH-Income Populations…

■■

There are high rates of poverty, illiteracy, and unemployment, which can have negative effects on personal, family, and community health.

■■

Most people have access to the basic tools for health, although there are still health disparities based on socioeconomic status.

■■

Many people do not have access to an outhouse or other type of toilet and many do not have reliable access to safe drinking water.

■■

Almost everyone has indoor plumbing and safe drinking water.

■■

Many infants and young children die from diarrhea, pneumonia, malaria, and other infections.

■■

Almost every baby will survive to adulthood.

■■

The typical woman gives birth to many children, and it is not uncommon for women to die in childbirth.

■■

The typical woman gives birth to 1 or 2 children, and very few women die due to pregnancy-related conditions.

■■

The median (average) age of the population is in childhood.

■■

The median (average) age of the population is in adulthood.

■■

A typical age at death for adults is 60 or 70 years old.

■■

A typical age at death for adults is 80 or even 90 years old.

■■

Visits to hospitals and clinics are usually because of infections (such as malaria or tuberculosis) or serious injuries.

■■

Visits to hospitals and clinics are usually due to chronic noncommunicable diseases (such as arthritis, back pain, hypertension, and diabetes).

■■

Access to effective management of chronic diseases (such as hypertension and diabetes) is very limited.

■■

Screening tests (such as mammography for breast cancer) often detect emerging health problems early, when they are usually more treatable.

■■

Undernutrition (including protein energy and micronutrient deficiencies) remains a significant public health concern.

■■

Overweight and obesity are major public health concerns, and many people have diets that are excessively high in fat and calories.

■■

Very few people with mental health disorders receive clinical care because there are so few psychiatrists and psychologists.

■■

Clinical mental health services are usually available, but they are often underused.

■■

Serious injuries often lead to death because no surgical services are available.

■■

Serious injuries can often be treated with surgery and rehabilitation

FIGURE 1–10  Examples of significant differences in health status and access to the tools for health in low-income and high-income countries.

12

Chapter 1 Global Health Transitions

illustrate the wide gaps in health status.18 A baby born in Japan in 2015 could expect to live to about 84 years old, but a newborn in Sierra Leone, in West Africa, could only expect to live to age 50. A woman giving birth in Sierra Leone in 2015 was about 450 times more likely to die of a pregnancy-­related condition than a pregnant woman living in Finland, in northern Europe. A baby born in Angola, in southwestern Africa, was nearly 80 times more likely to die before his or her fifth birthday than a baby born in Iceland. A 30-year-old living in Mongolia, in central Asia, was 3.5 times more likely to die from heart disease, cancer, chronic respiratory diseases, or diabetes before age 70 than an adult of the same age living in Switzerland. Those multipliers would not have been as high 100  years ago when no one had access to neonatal intensive care units, advanced obstetric care, antibiotics, and medications for managing chronic diseases. As some populations have gained access to more tools for health, and others have not, the disparities in the health profiles of high- and low-income countries have become more extreme. Middle-income countries tend to have inter­mediate health profiles with statistics somewhere between those of high-income and low-income countries. Many middle-­income countries continue to have some populations burdened by undernutrition and infectious diseases while, at the same time, other populations within the same country experience the challenges associated with obesity and chronic noncommunicable conditions. This need for the health system in middle-­income countries to address both “pre-­transition” and “post-transition” health problems is sometimes called the “dual burden” of disease. Comparing high-, middle-, and low-income countries provides insights into how health transitions occur and insights into the types of interventions that are likely to be effective at achieving particular types of changes in population health status.

▸▸

1.5  World Regions and Featured Countries

Throughout this book, data from eight large countries will be used to represent the diversity of the world’s health profiles, including the three countries with the largest populations— China and India, which each have more than 1 ­billion residents, and the United States, which has more than 320 million inhabitants—as well as five other countries that are among the 19 countries that are each home to more than 1% of the world’s population (that is, more than 75 million people).19 Together, these eight countries are home to half of the world’s people (FIGURE 1–11). The featured countries represent a diversity of economic profiles (FIGURE 1–12). The World Bank divides countries into four categories based on the gross national income per person. Of the eight featured countries, two are classified as high income, three as upper-­ middle income, two as lower-middle income, and one as low income. This classification is

China

Rest of the world

India

United States Brazil Nigeria Iran Ethiopia Germany

FIGURE 1–11  The eight featured countries represent nearly half of the world’s population. Data from World development indicators 2016. Washington DC: World Bank; 2016.

1.5  World Regions and Featured Countries

Country

World Bank Income Group

UNDP Human Development Level

United States

High

Very high

Germany

High

Very high

Iran

Upper middle

High

Brazil

Upper middle

High

China

Upper middle

High

India

Lower middle

Medium

Nigeria

Lower middle

Low

Ethiopia

Low

Low

13

FIGURE 1–12  Eight featured countries by income group. The countries are listed in order from highest to lowest human development index. Data from World development indicators 2016. Washington DC: World Bank; 2016. Human development report 2016. New York: UNDP; 2016.

similar to the distribution of the world’s population by income level, since 70% of the world’s people live in a country classified as middle income by the World Bank (FIGURE  1–13).19 Many analyses of global health compare the health status in low- and middle-income countries (LMICs), a category that includes all low-income, lower-middle-­income, and upper-middle-income countries, to the health status in high-income countries (HICs). Some global health reports compare LMICs to countries that are members of the Organisation for Economic Co-operation and Development (OECD), an intergovernmental organization that represents about three dozen of the world’s richest countries. Six of the eight featured countries in this book are LMICs and two are OECD-member HICs. The United Nations Development Programme (UNDP) divides countries into four groups (very high, high, medium, and low) based on a human development index calculated from income per person plus statistics

about longevity and education.20 These categories generally align with the World Bank group classifications, but one of the featured lowermiddle-­income countries (Nigeria) is classified as having a low rather than a medium human development level. The featured countries also represent geographic diversity (FIGURE 1–14), covering all seven World Bank analytical regions and all six of the WHO’s regions (FIGURE 1–15). There is often considerable diversity in the socioeconomic and health profiles of countries within the same world region. There is also considerable diversity among different states or provinces within countries and between urban and rural areas. These types of ­within-country differences can be observed in all eight of the featured countries. For example, parts of southern Nigeria have a middle-income economic profile while some of the northern areas of Nigeria have a very low-income profile and are at risk of famine.21 National statistical reports present the average values for various metrics, and those averages do not

14

Chapter 1 Global Health Transitions UNDP human development level

World bank income group

Low High

Very high

Lower middle Upper middle

High

Low

Medium

Featured countries

United States

Ethiopia

Germany

Nigeria

Iran

India Brazil

China

FIGURE 1–13  Most of the world’s people live in a country classified as middle income by the World Bank. Data from World development indicators 2016. Washington DC: World Bank; 2016; Human development report 2016. New York: UNDP; 2016.

express the wide range of values that may be present within diverse regions of the country. Despite that limitation, general patterns can be observed by comparing ­statistics from large countries. The differences between higherincome (high- and upper-­middle-income) countries and lower-­income (­lower-middle and low-income) countries are often notable (­FIGURE 1–16). For example, data from just the

eight featured countries are sufficient to illustrate the patterns associated with the fertility transition (women in higher-­income countries have fewer babies), the obstetric transition (higher-income countries have lower rates of maternal mortality), and the aging transition (higher-income countries have older populations) (FIGURE 1–17).20 Similar trends can be observed for a great diversity of indicators.

1.5  World Regions and Featured Countries

USA Germany Iran Brazil China India Nigeria Ethiopia

FIGURE 1–14  Eight featured countries representing nearly half of the world’s population. Data from World development indicators 2016. Washington DC: World Bank; 2016.

Country

Geographic Location

World Bank Region

WHO Region

United States

North America

North America

Americas

Germany

Europe

Europe and Central Asia

Europe

Iran

Middle East

Middle East and North Africa

Eastern Mediterranean

Brazil

South America

Latin America and the Caribbean

Americas

China

East Asia

East Asia and Pacific

Western Pacific

India

South Asia

South Asia

South-East Asia

Nigeria

West Africa

Sub-Saharan Africa

Africa

Ethiopia

East Africa

Sub-Saharan Africa

Africa

FIGURE 1–15  Eight featured countries by geographic location. World development indicators 2016. Washington DC: World Bank; 2016; World health statistics 2016: Monitoring health for the SDGs. Geneva: WHO; 2016.

15

16

Chapter 1 Global Health Transitions HIGHER income

HIGH income

LOWER income

UPPER MIDDLE income

LOWER MIDDLE income

LOW income

OECD

FIGURE 1–16  Income-level terminology.

USA

USA

Germany

Germany

Iran

Iran

Brazil

Brazil

China

China

India

India

Nigeria

Nigeria

Ethiopia

Ethiopia 0

1

USA

USA

Germany

Germany

Iran

Iran

Brazil

Brazil

China

China

India

India

Nigeria

Nigeria

Ethiopia

Ethiopia 0

814 Number of women who die of pregnancy-related conditions per 100,000 live births

FIGURE 1–17  Examples of socioeconomic and health trends. Data from Human development report 2016. New York: UNDP; 2016.

6

0

Average number of births per woman

Human development index (HDI)

0

50 Median age

1.6  Global Health Security

▸▸

1.6  Global Health Security

The goal of the first international health initiatives was to prevent widespread outbreaks of infectious diseases. For example, a series of International Sanitary Conferences held in various European cities starting in 1851 assembled representatives from several countries to address concerns about travel and trade spreading cholera to new ports.22 Signatories of the resulting agreements agreed to notify other countries about outbreaks of cholera, plague, yellow fever, and other epidemic diseases, and they pledged to monitor health at ports and impose quarantines on disease-­ carrying ships.23 These treaties set the stage for the International Sanitary Regulations (later renamed the International Health Regulations) that were approved by the WHO 100 years later in 1951 and are still in force today. By the early 1900s, international regulations addressed several other cross-border health issues, including drugs and alcohol sales, occupational health and safety, and water pollution,24 but the initial impetus for these deliberations was the recognition that countries had to collaborate with their neighbors to keep dangerous pathogens at bay. A second set of early international health concerns focused on threats to economic and political interests. The field of tropical ­medicine blossomed in the late 1800s and early 1900s as more European (and American) military personnel, businessmen, and their families relocated to colonies in tropical climates.25 Tropical medicine specialists aimed not only to protect settlers from parasitic and infectious diseases—a role similar to that of travel medicine specialists today—but also to ensure that the workforce in these areas could be productive.26 Today, tropical medicine has expanded to become international health,10 a term that now typically refers to initiatives targeted toward addressing poverty-related health conditions in lower-income areas, no

17

matter which geographic region they happen to be located in.27 While many international health programs are humanitarian, they also enable workers and consumers in the recipient countries to remain active participants in the global economy. Human security was defined in the 1994 Human Development Report as the freedom from fear and want that results from having health security as well as food security (freedom from hunger), personal security (freedom from violence), environmental security (freedom from preventable environmental vulnerabilities), economic security (freedom from extreme poverty), community security (freedom from discrimination), and political security (freedom from human rights violations).28 Human security focuses on individual and community well-being, while national security focuses on the protection of the collective interests of people living within a country’s borders. For many countries, promoting health security and other aspects of human security in other countries is a core component of national security plans.29 The investment in global health activities by high-income countries generates major returns through expanded markets for international trade, strengthened diplomatic relationships, and fortified homeland security.30 The nascent field of global health ­security seeks to protect populations from threats to health and safety by engaging a diversity of stakeholders, including governmental and military personnel, in public health interventions.31 The current concept of global health security is an extension of the historic international health policies and practices that aimed to stem the spread of epidemics as international travel and trade became more common.32 Communities and countries suffering from widespread health problems are more likely to have political and economic instability, and poverty and unrest can further exacerbate public health problems that might spill over into other parts of the world. International and global health

18

Chapter 1 Global Health Transitions

initiatives can help to break this cycle, facilitating peace and productivity. Global health security recognizes that countries participating in global health activities reap the benefits of self-protection in addition to the humanitarian gains and goodwill that these actions may generate.33

▸▸

1.7  Globalization and Health: Shared Futures

Globalization is the process of countries around the world becoming more integrated and interdependent across economic, political, cultural, and other domains. Globalization contributes to the health transitions that are occurring in many parts of the world by increasing access to health technologies, encouraging urbanization, changing social and cultural practices, and accelerating environmental changes.34 Globalization can also be observed in the increasing number of global governmental and nongovernmental organizations, the proliferation of multilateral trade agreements, and increases in global supply chains, foreign direct investment, population mobility, communication, data sharing, and cultural diffusion. The concept of globalization is not new to the field of public health. Infectious diseases like plague and smallpox spread across Asia and Europe more than a 1000 years ago, when sea and land trade routes like the Silk Road linked China, India, and the Mediterranean. The pathogens carried by the Europeans who explored the Americas in the 15th century caused the decimation of many indigenous American populations, while some infections indigenous to the Western hemisphere (such as syphilis) made their way back to Europe and sparked mass epidemics.35 Pathogens have never stopped at national boundaries, and modern transportation allows for a new infectious disease that emerges in any part of the world to be transported by aircraft to any

other part of the world within hours rather than weeks or months. Concerns about globalization and health also encompass a diversity of other emerging health issues, like bioterrorism, drug resistance, food safety, and the health effects of climate change. Globalization is not a uniformly good or bad process, but one that yields a mix of positive and negative outcomes.36 For example, globalization has allowed more goods to be manufactured in middle-income countries and then sold in high-income countries where higher salaries for workers make manufacturing comparatively expensive. In middle-­ income countries, globalization often means more job opportunities, but there may also be pressures to increase productivity even if that causes environmental damage or creates unsafe working conditions. In high-income areas, international trade reduces the cost of consumer products but it also means that there are fewer local jobs in the manufacturing sector. Cheaper products created in middle-­ income countries also make it harder for the lowest-income countries to participate in the global economy because the poorest countries do not have educational systems geared toward producing a technologically skilled workforce. Globalization tends to create greater inequalities in income between countries and within countries. Concerns about the adverse impacts of globalization have led in many countries to the rise of nationalistic political movements that call for greater self-reliance and less engagement with other nations. However, even if countries implement isolationist policies, it is not possible to eliminate the need for involvement in global health activities. The threat from emerging infectious diseases is an ancient one that will continue to exist for future generations, and environmental hazards can easily cross international borders when they are carried by air, water, or animals. Whether a country has pro- or anti-­globalization policies, it is in every country’s best interests to actively engage in

References

communicating about transnational health concerns, sharing the scientific discoveries that enable populations to fortify themselves against threats to health, and collaborating on health interventions that promote peace, prosperity, and security. Global health offers a proactive way to prevent outbreaks (and to respond to them when they happen), to protect economic and political interests at home and abroad, to promote goodwill and humanitarian values, and to achieve shared health and development goals.37 Global health is a dynamic field. The health patterns that exist today are not the same as the patterns from 100 years ago, and new health transitions will occur in the coming decades. Global health provides an opportunity to use prevention strategies and other interventions to shape a healthier, safer future for the world’s people.

▸▸

References

1. Huber M, Knottnerus JA, Green L, et al. How should we define health? BMJ. 2011;343:d4163. 2. Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J, Power C. Life course epidemiology. J Epidemiol Community Health. 2003;57:778–83. 3. Committee on Assuring the Health of the Public in the 21st Century. The future of the public’s health in the 21st century. Washington DC: National Academies Press; 2002. 4. Susser M, Susser E. Choosing a future for epidemiology: I. Eras and paradigms. Am J Public Health. 1996;86:668–73. 5. Bingham P, Verlander NQ, Cheal MJ. John Snow, William Farr and the 1849 outbreak of cholera that affected London: A reworking of the data highlights the importance of the water supply. Public Health. 2004;118:387–94. 6. Shryock RH. The early American public health movement. Am J Public Health. 1937;27:965–71. 7. Pearce N. Traditional epidemiology, modern epide­ miology, and public health. Am J Public Health. 1996;86:678–83. 8. Doll R, Hill AB. Lung cancer and other causes of death in relation to smoking. Br Med J. 1956;2:1071–81. 9. Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ. 1997;315:980–8.

19

10. Packard RM. A history of global health: Interventions into the lives of other peoples. Baltimore MD: Johns Hopkins University Press; 2016. 11. Harrell JA, Baker EL; Essential Services Work Group. The essential services of public health. Leadersh Public Health. 1994;3:27–30. 12. The Ottawa Charter for Health Promotion. Ottawa: 1st International Conference on Health Promotion; 1986. 13. Keller LO, Strohschein S, Lia-Hoagberg B, Schaffer MA. Population-based public health interventions: Practice-based and evidence-supported. Public Health Nurs. 2004;21:453–68. 14. Flay BR, Biglan A, Boruch RF, et al. Standards of evidence: Criteria for efficacy, effectiveness and dissemination. Prev Sci. 2005;6:151–75. 15. Jones DS, Podolsky SH, Greene JA. The burden of disease and the changing task of medicine. New Engl J Med. 2012;366:2333–8. 16. Guyer B, Freedman MA, Strobino DM, Sondik  EJ. Annual summary of vital statistics: Trends in the health of Americans during the 20th century. Pediatrics. 2000;106:1307–17. 17. Martens P. Health transitions in a globalising world: Towards more disease or sustained health? Futures. 2002;34:635–48. 18. World health statistics 2016: Monitoring health for the SDGs. Geneva: WHO; 2016. 19. World development indicators 2016. Washington DC: World Bank; 2016. 20. Human development report 2016. New York: UNDP; 2016. 21. National human development report 2015: Human security and human development in Nigeria. Abuja: UNDP Nigeria; 2015. 22. Huber V. The unification of the globe by disease? The International Sanitary Conferences on cholera, 1951–1894. Historical J. 2006;49:453–76. 23. Fidler DP. From International Sanitary Conventions to global health security: The new International Health Regulations. Chinese J Int Law. 2005;4:325–92. 24. Fidler DP. The globalization of public health: The first 100 years of international health diplomacy. Bull World Health Organ. 2001;79:842–9. 25. Gibson AD. Miasma revisited: The intellectual history of tropical medicine. Aust Fam Physician. 2009;38:57–9. 26. Brown ER. Public health in imperialism: Early Rockefeller programs at home and abroad. Am J Public Health. 1976;66:897–903. 27. Koplan JP, Bond TC, Merson MH, et al. Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993–5. 28. Human development report 1994. New York: UNDP; 1994.

20

Chapter 1 Global Health Transitions

29. Oslo Ministerial Declaration: Global health: A pressing foreign policy issue of our time. Lancet. 2007;369:1373–8. 30. The Case for U.S. Investment in the Global Fund and Global Health. Washington DC: Friends of the Global Fight against AIDS, Tuberculosis and Malaria; 2017. 31. Aldis W. Health security as a public health concept: A critical analysis. Health Policy Plan. 2008;23:369–75. 32. Hoffman SJ. The evolution, etiology and eventualities of the global health security regime. Health Policy Plan. 2010;25:510–22.

33. Lakoff A. Two regimes of global health. Humanity. 2010;1:59–79. 34. McMichael AJ. Globalization, climate change, and human health. N Engl J Med. 2013;368:1335–43. 35. Morens DM, Folkers GK, Fauci AS. Emerging infections: A perpetual challenge. Lancet Infect Dis. 2008;8:710–19. 36. Osland JS. Broadening the debate: The pros and cons of globalization. J Manage Inquiry. 2003;12:137–54. 37. Global health works: Maximizing U.S. investments for healthier and stronger communities. Washington DC: Global Health Council; 2017.

© Xinzheng. All Rights Reserved/Moment/Getty

CHAPTER 2

Global Health Priorities Global health priorities are established based on population needs assessments, economic evaluations of the tools that are available to deploy as interventions, donor values, and security considerations. Health metrics provide valuable information for priority-setting, decision-making, and monitoring of progress toward achieving global health targets. Global partnerships for development like the Sustainable Development Goals also shape the global health agenda and encourage transnational cooperation to address shared priorities.

▸▸

2.1  Global Health Achievements

Innovations in health technology during the last century have created an incredible set of tools for global health work. New antibiotics were discovered along with a host of medications for treating noncommunicable diseases (NCDs) like heart disease and cancer. Life-­ saving vaccines were developed. Smallpox was eradicated. Oral contraceptives transformed family planning, and assisted reproductive technologies enabled many couples with infertility problems to have biological children. New diagnostic tools, such as ­electrocardiographs and MRIs, increased the quality of medical care, as did new therapies, like insulin for diabetes, dialysis for kidney disease, and contact lenses for vision impairments. Modern surgical techniques made joint replacements, open heart surgery, and organ transplants routine in some parts of

the world. These technological advances enabled many of the top 10 public health achievements of the 20th century that were highlighted by the U.S. Centers for Disease Control and Prevention (CDC) at the start of the new millennium (FIGURE 2–1)1 as well as many of the leading global health achievements during the first years of the 21st century (FIGURE 2–2).2 While these health technologies are indisputably beneficial, the uneven distribution of access to them has generated a massive intensification of health disparities. People living in the world’s richest countries now have access to an array of tools for health that would have been unimaginable 100 years ago, while children living in the world’s poorest areas continue to succumb to easily preventable conditions like starvation and vaccine-preventable and ­antibiotic-treatable infectious diseases. At the same time that the health profiles of populations worldwide were becoming more 21

22

Chapter 2 Global Health Priorities

1

Vaccination

1

Reductions in child mortality

2

Motor-vehicle safety

2

Vaccine-preventable diseases

3

Safer workplaces

3

Access to safe water and sanitation

4

Control of infectious diseases

4

Malaria prevention and control

5

Decline in deaths from ischemic heart disease and stroke

5

Prevention and control of HIV/AIDS

6

Tuberculosis control

6

Safer and healthier foods 7

Control of neglected tropical diseases

7

Healthier mothers and babies 8

Tobacco control

8

Family planning 9

9

Fluoridation of drinking water

Increased awareness and response for improving global road safety

10

Improved preparedness and response to global health threats

10

Recognition of tobacco as a health hazard

FIGURE 2–1  The U.S. CDC’s top 10 public health achievements of the 20th century (1900–1999). Reproduced from Ten great public health achievements: United States, 1990–1999. MMWR Morb Mort Wkly Rev 1999;48:241–3.

disparate, the 20th century brought potent reminders that all people around the world are at risk from a shared set of hazards. The emergence of HIV, virulent new strains of influenza, and drug-resistant pathogens prompted truly global research and response efforts. The goals of global health in the 21st century are to continue to create innovative solutions to public health problems; to increase access to health, healthcare services, and health technologies around the world; and to expand global communication and action about shared health concerns. In an ideal world, there would be enough resources for all worthy global health goals to receive the funding they need to be achieved.

FIGURE 2–2  The U.S. CDC’s top 10 global health achievements in the first decade of the 21st century (2001–2010). Data from CDC, Ten great public health achievements: Worldwide, 2001–2010. MMWR Morb Mort Wkly Rev 2011; 60:814-8.

In the real world, the amount of funding available for health interventions is limited. Advocates for various health problems and solutions must compete for attention and support, and only the proposals that garner buy-in from well-resourced groups are able to move forward. The gap between commendable ideas and the resources to implement them has created a demand for prioritization strategies that allow funders to make informed decisions about where and how to invest in global health. When future generations compile lists celebrating the major global health accomplishments of the 21st century, those lists will reflect the decisions today’s global health leaders make about which projects to prioritize.

2.2  Prioritization Strategies

▸▸

2.2 Prioritization Strategies

Funding agencies and planning committees use a variety of strategies to prioritize the types of activities that they will support.3 For example, some focus specifically on health and nutrition interventions, while others support broader education and economic development activities that enable healthier communities. Some give priority to prevention activities, and some prioritize treatment of existing health issues. Some prepare primary health facilities to address a diversity of health issues, and some focus on increasing access to advanced disease-specific care at tertiary hospitals. The priorities identified by groups viewing global health with different lenses provide insight into the common health challenges of nations and

populations around the world, and they point toward solutions for shared concerns. The PACES definition of global health—one that considers populations, action, cooperation, equity, and security to be identifiers of global health issues—also provides a framework for prioritizing items for the global health agenda (FIGURE 2–3). One approach is to establish priorities based on the health concerns that affect the most people. The term burden of d ­ isease (BOD) refers to the adverse impact of a particular health condition (or group of conditions) on a population. Disease burden can be measured using health metrics (like the number of deaths from a particular disease) and economic indicators (like the total direct costs of medical care for a disease plus the indirect costs of absences from work or school due to the condition). Groups that

Lens

Key Questions

Populations

What are the health issues that cause the greatest number of deaths, illnesses, and disability worldwide? Which populations have the greatest need?

Action

What are the “best buys” among the available interventions? How do we allocate resources to do the greatest good for the greatest number of people?

Cooperation

What are the goals of the partners? What problem is the partnership best equipped to solve?

Equity

What actions will do the most to improve the lives of children and other vulnerable populations? How will the intervention reduce health disparities?

Security

23

What are the greatest threats to peace? How will the intervention help to achieve the national interests of sponsoring governments?

FIGURE 2–3  PACES: strategies for prioritizing global health issues.

24

Chapter 2 Global Health Priorities

prioritize global health spending based on a population lens make their decisions after looking at statistics about the conditions that cause the greatest BOD. For example, the Global ­Burden of Disease (GBD) project, a massive collaborative effort to quantify the epidemiologic profiles of every country in the world that was initiated by the World Health Organization (WHO) in the 1990s and is now housed at the Institute for Health Metrics and Evaluation (IHME) in Seattle has identified unhealthy diets, child and maternal undernutrition, untreated high blood pressure, tobacco smoke, and indoor and outdoor air pollution as some of the most common modifiable exposures that cause poor health and early death globally.4 The evidence that these risk factors cause a substantial BOD can be used to support proposals for interventions that will enable a large number of people to live longer, healthier lives. The GBD collaborators also release annual estimates of the causes of death, illness, and disability worldwide and for each country. These numbers inform the development of policy recommendations that can be acted on by governmental bodies and other public health funders and implementers. Prioritization based on an action orientation often gives the highest ratings to the cost-effective interventions that have been identified as “best buys” because they help many people make meaningful gains in health status at a low cost per person (or at a low cost per adverse event averted by the intervention).5 In general, low-cost primary prevention activities are the most cost-­effective interventions.6 The Disease Control Priorities (DCP) project has identified vaccinating children, preventing malaria and HIV infections, treating tuberculosis and common communicable childhood diseases to prevent them from spreading to other people, improving the basic care of newborns, distributing micronutrients to children and pregnant

women, taxing tobacco products to reduce use, expanding the use of cardiovascular medications to prevent heart attacks and strokes, and enforcing traffic laws to reduce injuries as some of the highest-impact global health interventions (FIGURE 2–4).7 Some groups make decisions based on the special interests and capabilities of the collaborators. For example, the 14 Grand Challenges in Global Health identified by the Bill & Melinda Gates Foundation in 2003 highlighted critical needs for new health technologies (FIGURE 2–5),8 and the Gates Foundation subsequently used that list as part of selecting proposals to fund. Because the Gates Foundation is led by people with expertise in computers and information technology, the foundation is uniquely prepared to support the development and dissemination of new tech products. When funding and implementation agencies have particular areas of expertise, they can maximize their impact by applying their existing knowledge and experience toward new projects that build on past successes. Groups focused on equity prioritize projects that will address perceived injustices and reduce health disparities. Many equity-­ oriented programs focus on the health of infants and children because of the nearly universal belief that no child anywhere should suffer from abuse, hunger, or preventable diseases.9 Equity-focused initiatives may also focus on the health of other vulnerable populations, like refugees and other migrants, people in prison, people with disabilities, and older adults, or they may advocate for human rights. Another common approach is to make prioritization decisions based on the security interests of sponsoring governments, including direct and indirect threats to national, regional, and global peace and stability. For example, the top public health challenges that the U.S. CDC has identified for the United States

2.2  Prioritization Strategies

25

Target

Action

1

Child health

Vaccinate children against major childhood killers, including measles, polio, tetanus, whooping cough, and diphtheria.

2

Child health

Monitor children’s health to prevent or, if necessary, treat childhood pneumonia, diarrhea, and malaria.

3

Tobacco use

Tax tobacco products to increase consumers’ costs by at least one-third to curb smoking and reduce the prevalence of cardiovascular disease, cancer, and respiratory disease.

4

HIV/AIDS

Attack the spread of HIV through a coordinated approach that includes promoting 100% condom use among populations at high risk; treating other sexually transmitted infections; providing antiretroviral medications, especially for pregnant women; and offering voluntary HIV counseling and testing.

5

Maternal and child health

Give children and pregnant women essential nutrients, including vitamin A, iron, and iodine, to prevent maternal anemia, infant deaths, and long-term health problems.

6

Malaria

Provide insecticide-treated bednets in malaria-endemic areas to drastically reduce malaria.

7

Injury prevention

Enforce traffic regulations and install speed bumps at dangerous intersections to reduce traffic-related injuries.

8

TB

Treat TB patients with short-course chemotherapy to cure infected people and prevent new infections.

9

Child health

Teach mothers and train birth attendants to keep newborns warm and clean to reduce illness and death.

Cardiovascular disease

Promote use of aspirin and other inexpensive medications to treat and prevent heart attack and stroke.

10

FIGURE 2–4  Ten “best buys” in global health from the Disease Control Priorities Project. Reproduced from Pathways to global health research: strategic plan 2008–2012. Bethesda MD: The John E. Fogarty International Center, National Institutes of Health (NIH); 2008, p. 22.

26

Chapter 2 Global Health Priorities

1

Create effective single-dose vaccines.

2

Prepare vaccines that do not require refrigeration.

3

Develop needle-free vaccine delivery systems.

4

Devise testing systems for new vaccines.

5

Design antigens for protective immunity.

6

Learn about immunological responses.

7

Develop genetic strategy to control insects.

8

Develop chemical strategy to control insects.

Improve nutrition to promote health

9

Create a nutrient-rich staple plant species.

Improve drug treatment of infectious diseases

10

Find medications and delivery systems to limit drug resistance.

11

Create therapies that can cure latent infection.

12

Create immunological methods to cure latent infection.

13

Develop technologies to assess population health.

14

Develop versatile diagnostic tools.

Improve childhood vaccines

Create new vaccines

Control insects that transmit agents of disease

Cure latent and chronic infection

Measure health status accurately and economically in developing countries

FIGURE 2–5  Grand Challenges in Global Health. Data from Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA. Grand challenges in global health. Science 2003; 302:398-9.

include protecting the environment, responding to emerging infectious diseases (including pandemic influenza and drug-resistant pathogens), and reducing the burden from violence (including the physical and psychological traumas sustained by military personnel deployed to conflict areas) (FIGURE 2–6).10 These types of threats to health and security cannot be

alleviated by any one country working in isolation. Once a country has identified its own strategic global health priorities, that country is prepared to advocate for those priorities in conversations with potential partners. Working with partner nations on achieving shared aims will then advance health security at home and abroad.

2.3  Health Metrics

1

Institute a rational healthcare system (balance equity, cost, and quality).

2

Eliminate health disparities.

3

Focus on children’s emotional and intellectual development.

4

Achieve a longer “healthspan” (healthy aging).

5

Integrate physical activity and healthy eating into daily lives.

6

Clean up and protect the environment.

7

Prepare to respond to emerging infectious diseases.

8

Recognize and address the contributions of mental health to overall health and well-being.

9

Reduce the toll of violence in society.

10

27

Use new scientific knowledge and technological advances wisely.

FIGURE 2–6  The U.S. CDC’s top public health challenges for the early 21st century. Data from Koplan JP, Fleming DW. Current and future public health challenges. JAMA 2000; 284:1696-8.

▸▸

2.3  Health Metrics

As more resources have been devoted to global health efforts, it has become increasingly important to quantify the health needs in various parts of the world, identify major modifiable risk factors for common diseases, assess the impact of new public health interventions, and monitor changes in the health status of populations over time. The key measures of health and disease in populations include information about population size, the birth rates and death rates, the causes of death, the frequency and causes of various illnesses and disabilities, and the rate at which members of the population engage in risky behaviors. All of these measures provide an evidence base for making policy and funding decisions.11 Health information comes from a wide variety of sources, including census data, registries, surveillance systems, household surveys, and health services records, such as hospital

patient files and insurance claims.12 Many types of health data are disseminated through the websites and annual reports of major governmental and nongovernmental health organizations and through academic journal articles. The websites of the WHO, the U.S. CDC, the U.S. National Institutes of Health (NIH), and other health agencies provide easyto-read and regularly updated information about hundreds of diseases. For example, the WHO’s Weekly Epidemiological Record and the CDC’s Morbidity and Mortality Weekly Report (MMWR) provide timely information about emerging health issues, such as new outbreaks of serious infections. For comparative global health statistics, the best sources are often the appendices of the annual reports of UN agencies, such as the WHO’s annual World Health Statistics report and UNICEF’s annual State of the World’s Children report. For disease-specific statistics, the reports of specialty organizations can be

Chapter 2 Global Health Priorities

n Br az i C l hi na In di a N ig er E t ia hi op ia

Ira

an y

er

m

U SA

40 35 30 25 20 15 10 5 0

G

helpful references. For example, some global cancer statistics are reported every year by the American Cancer Society and by the International Agency for Research on Cancer (IARC), which is part of the UN system. For detailed information about particular research methods and findings, the best sources are academic and professional journals articles that have undergone peer review, which means that before the papers were published, the manuscripts were sent to experts in the field who scrutinized the methodology and evaluated the validity of the results. An abstract is a one-paragraph summary of the methods, results, and conclusions of a scientific investigation. Abstract databases like MEDLINE can be used to search for abstracts summarizing journal articles on selected topics. The full reports can then be found online or in a library. These various types of high-quality resources provide an e­ vidence-based foundation for those who seek to create, implement, evaluate, or improve global public health p ­ olicies and practices. Most countries maintain vital statistics on their residents, population-level metrics about births, deaths, and other life events. Vital statistics are compiled from birth and death certificates, marriage and divorce certificates, census records, and other sources. Demographers use these statistics to understand the current population distribution and predict the size and characteristics of the population in future years. The birth rate is the annual number of births per 1000 people in the total population. The birth rate is usually highest in the lowest-income countries (FIGURE 2–7). The death rate, also called the mortality rate, is the annual number of deaths per 1000 people (or other units, such as per 100,000 people). Mortality rates can be presented for all-cause mortality and for specific causes of death. The all-cause death rate is usually higher in populations with a large percentage of older adults than in populations with an abundance of school-aged children because age-­specific

Birth rate per 1000

28

FIGURE 2–7  Birth rate per 1000 people in 2015 in featured countries. Data from World development indicators 2016. Washington: World Bank; 2016.

mortality rates are higher for older adults than for younger people. Age-adjusted rates that account for differences in population age structures are usually used to compare mortality rates in two or more populations. While the crude (unadjusted) all-cause mortality rates are typically highest in high-income countries that have a large proportion of older adults, the age-­ standardized (adjusted) mortality rates are usually highest in low-income countries (FIGURE 2–8). Measuring mortality (death) at the population level can be challenging for two principal reasons. The first is that in many parts of the world there is no system for reliably registering vital statistics. In places where most births and deaths occur in homes instead of in hospitals, few births and deaths are documented by government officials. The most disadvantaged populations—often the ones with the highest mortality rates—are the least likely to have their life events accurately counted. Thus, while very precise mortality statistics are available from high-income countries, death rates in low-income countries often must be estimated based on limited data. The second key challenge is assigning one cause of death to each deceased individual. Should a person with HIV/AIDS who dies of tuberculosis be recorded as an HIV death or a TB death? Should a person with advanced-stage

2.3  Health Metrics

29

1400

Death rate per 100,00 people

1200

1000

800

600

400

200

0 Crude death rate

Age-standardized death rate

USA

Germany

Iran

India

Nigeria

Ethiopia

Brazil

China

Global average

FIGURE 2–8  Crude and age-standardized all-cause mortality rates per 100,000 people in 2015 in featured countries. Data from GBD Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1459-544.

cancer who dies of pneumonia be counted as a cancer death or an infectious disease death? These decisions about how to assign causes of death can have a significant impact on which diseases appear to be the most common causes of mortality in a population. Even with these limitations, epidemiologists using standardized estimation methods and the best available data can make reasonably accurate assessments of the annual number and causes of death by age group and sex in every region of the world. Another common way of examining mortality and survival at the population level is through the estimation of life expectancy (FIGURE 2–9). Life expectancy at birth is the

median expected age at death of all babies born alive. Life expectancy captures the burden from infant and child deaths in addition to the average age at death of adults. In places with high infant mortality rates, the median age at death is often in middle adulthood, which represents an age somewhere between a large number of child deaths and an even larger number of deaths in older adults. Life expectancies have increased over time in most countries, but they remain much higher in high-income countries than in low-income countries (FIGURE 2–10).13 Some estimates of life expectancy instead focus on healthy life expectancy (HALE), which is the number of years the average individual born into the

30

Chapter 2 Global Health Priorities

Missing/Excluded Less than 60 60 to 70 70 to 75 75 to 80 80 and above

FIGURE 2–9  Life expectancy at birth (2015). Data from World development indicators 2016. Washington: World Bank; 2016.

90

Life expectancy at birth

80 70 60 50 40 30 20 10 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 USA China

Germany India

Iran Nigeria

Brazil Ethiopia

FIGURE 2–10  Life expectancy has increased over time. Data from United Nations Department of Economic and Social Affairs. World population prospects: the 2017 revision. New York: UN; 2017.

2.3  Health Metrics

Male Male Female Male Female

Brazil

Male Female Female

Ethiopia Nigeria India

cases of the disease occurring in a time period divided by the total number of people at risk for that disease in that time period. Incidence is usually used to study infectious diseases, acute diseases (diseases that occur suddenly), and outbreaks. Prevalence is the number of total existing cases, whether newly diagnosed or long-established, divided by the total number of people in the population at the time the prevalence is measured. Prevalence is usually used to describe the frequency of chronic (long-lasting) exposures and diseases in a population, such as the percentage of adults in a country who have diabetes or asthma or who smoke tobacco products.

Female

China

Iran Germany USA

population can expect to live without disability (FIGURE 2–11).14 In most countries, adults experience about 10 years in poor health before dying. Global health aims to increase life expectancies and increase HALEs, so that people live to older ages without experiencing extended periods of disability prior to death. Morbidity refers to the presence of illness or disease, whether that disease is relatively mild, like the common cold, or quite severe. The two most common terms used to describe the morbidity rate for a particular disease in a population are incidence and prevalence (FIGURE 2–12). Incidence is the number of new

Male Male Female Male Female Male Female 0

31

20

40

60

80

Life expectancy at birth HALE at birth

Total LE at birth

FIGURE 2–11  Life expectancy and healthy life expectancy (HALE) at birth. Data from GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1603-58.

32

Chapter 2 Global Health Priorities

December 31, 2017

December 31, 2018

At the end of 2017, there were 100 adult residents of Villagetown and 20 of them had HIV infection.

At the start of 2018, there were 80 susceptible adults in Villagetown. During 2018, 8 became newly infected with HIV.

The prevalence of HIV infection was 20/100 = 20%.

The one-year incidence rate of HIV infection was 8/80 = 1/10. One in 10 susceptible adults became infected.

Assuming that all of the adults survived to the end of 2018, there were 100 adult residents of Villagetown and 28 of them had HIV infection. The prevalence of HIV infection was 28/100 = 28%

FIGURE 2–12  An example of incidence and prevalence.

Epidemiologists measuring incidence and prevalence must establish a clear case definition that spells out exactly which characteristics indicate that a person has (or does not have) the conditions of interest. They must also have a system in place for ascertaining the total number of people in the population being studied, especially if changes in the health status of a population are being tracked over time and the population might be growing or shrinking or aging. Age-adjustment can be used to standardize two populations with different age structures before their morbidity rates are compared. A variety of more complex health metrics also are used to examine the disease burden at the population level. Years of life lost (YLLs) quantify the burden from premature mortality in a population. Premature mortality is any death before a selected target survival age. For example, if the goal is for everyone in a population to live to age 70, someone who dies at 60 years of age would contribute 10 YLLs to the population total. If the target for survival

is age 80, someone who dies at 60 years of age would contribute 20 YLLs to the population total. Diseases that kill children, who would have had decades of productive life remaining if they had survived, generate more YLLs per case than diseases that primarily affect older adults. An intervention that keeps one 5-yearold from dying will prevent the loss of up to 75 YLLs in a population that has a target survival age of 80 years, while an intervention that keeps a 75-year-old alive for at least 5 more years will generate only 5 averted YLLs. An intervention for people who are already older than the target survival age will not help reduce the number of YLLs in the population because only premature deaths count toward the total. In the models created for the GBD project, the term disability refers to any short- or long-term reduction in health status.15 Weights are assigned to the level of disability caused by each type of physical or mental health condition. Years lived with disability (YLDs) quantify the burden to a population from

2.3  Health Metrics

nonfatal health conditions that cause significant impairment and distress (FIGURE 2–13). The total number of YLDs in a population is a function of how often a condition occurs, how much disability the condition causes (that is, the weight associated with the disability), and how long the condition typically persists.16 A person who spends a year in a coma would

health status

ideal

death birth

very old age

A

ideal

YLDs

YLLs

death birth

very old age

B

FIGURE 2–13  Examples of years lived with disability (YLDs) and years of life lost (YLLs) to premature mortality for different health trajectories. YLLs 100%

+

YLDs

=

33

be considered fully disabled for that time period, contributing about one full YLD to the population total. Someone who is unable to work or go to school for 1 week due to a bout of influenza or a severely sprained ankle would contribute a tiny fraction of 1 YLD to the tally. The typical person contributes a small portion of one YLD to the population total each year. However, many small contributions from a particular cause can add up to a large number of YLDs across a population. Some of the most common causes of YLDs are back pain, depression, iron deficiency anemia, age-­related hearing loss, diabetes, and migraine headaches.17 A disability-adjusted life year (DALY) is a measure of the total burden of disease in a population from both premature deaths and disability. The total number of DALYs in a population is the sum of YLLs and YLDs. One of the key benefits of using DALYs is that it highlights the high burden of disability caused by mental health disorders, pain, and other causes of reduced health status that are usually not fatal (FIGURE 2–14).17 The main criticism of DALYs is the difficulty in assigning weights to the amount of disability caused by various illnesses and impairments. It will never be possible to assign an accurate weight to the decrease in quality of life caused by blindness, loss of a limb, depression, a brain tumor, or asthma, because the experience of disability varies so much based on the individual,

DALYs

Other Injuries

80% 60% 40% 20% 0%

Sense organ disorders (such as agerelated vision and hearing loss) Musculoskeletal disorders (such as back pain and arthritis) Mental health Cardiovascular disease, cancer, chronic respiratory diseases, and diabetes Infectious diseases

FIGURE 2–14  Global distribution of YLLs, YLDs, and DALYs in 2015. Data from GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1545-602.

34

Chapter 2 Global Health Priorities

living conditions, the level of community support, access to health care, and other individual factors. For example, the amount of disability caused by an amputated foot would be much higher for a manual laborer in a low-resource setting where prosthetics are not available than it would be for an office worker in a place where high-tech prosthetics are common. Economists frequently use health-­ adjusted life year estimates similar to the DALY as part of cost-effectiveness analyses. A ­quality-adjusted life year (QALY) quantifies the additional duration of life and quality of life conferred to populations by successful public health interventions.18 A DALY is a bad thing to be avoided (the loss of a healthy year of life), while a QALY is a good thing to save.19 While vital statistics and simple measures of morbidity (like incidence and prevalence) can be directly measured, more complicated health metrics like DALYs and QALYs are estimated using complex equations. The results of these types of computational models are dependent on the assumptions of the modelers, such as assumptions about the target survival age in a population and the disability weights assigned to various conditions. Health metrics from different populations should only be compared

1

5

Improve maternal health

▸▸

2.4 Millennium Development Goals

The Millennium Development Goals (MDGs)  that were adopted by the United Nations in 2000 and endorsed by nearly 200 countries worldwide were a major contributor to the global health successes thus far in the 21st century. The MDGs spelled out eight major goals for significantly reducing global poverty by 2015 (FIGURE 2–15).20 While the MDGs overall were about general socioeconomic development, most of the goals had direct links to health: eradicating extreme poverty and hunger (MDG 1); reducing child mortality (MDG 4); improving maternal health (MDG 5); combatting HIV/AIDS, malaria, and other diseases (MDG 6); and ensuring environmental sustainability (MDG 7). Each signatory country was committed to working toward these

2

3

Promote gender equality and empower women

Achieve universal primary education

Eradicate extreme poverty and hunger

when they were calculated based on similar methods and assumptions. Health metrics computed using the same methods allow different populations (or the same population at two points in time) to be compared.

6

Combat HIV/ AIDS, malaria and other diseases

4

Reduce child mortality

7

Ensure environmental sustainability

8

Develop a global partnership for development

FIGURE 2–15  Millennium Development Goals (MDGs) (2000–2015). Reproduced from United Nations. United Nations millennium development goals. http://www.un.org/millenniumgoals/. Reproduced with permission from UNDP Brazil.

2.4  Millennium Development Goals

goals, so the MDGs provided a blueprint for national- and international-level priority setting. One of the main reasons the MDGs were so influential is that they provided a clear strategy for evaluation. When the eight MDGs were launched in 2000, they were accompanied by 18 targets that spelled out benchmarks for success (many of which used 1990 as the baseline year for comparison) and 48 specific indicators that were used to evaluate progress toward achieving those targets. These were later expanded to 21 targets and 60 indicators. Data about each of the 60 indicators were collected annually from most participating countries and were used to determine how much progress had been made toward reaching the goals at national, regional, and global levels. While some concerns were raised about how well the MDGs promoted equity, sustainability, local ownership of priorities, and holistic development (rather than relatively narrow, single-sector silos of focus), the general consensus was that the MDGs provided a helpful framework for global cooperation toward international development.21

© 2018 United Nations.

35

The MDGs facilitated remarkable improvements in health status and quality of life for the world’s lowest-income populations. Globally, there was a 44% reduction in hunger between 1990 and 2015, a 53% reduction in the mortality rate among children between birth and their fifth birthdays between 1990 and 2015, a 44% reduction in pregnancy-­ related deaths during that time period, a 45% reduction in new cases of HIV compared to the rate in 2000, and a 62% reduction in the percentage of people without reliable access to safe drinking water sources.22 Although not all of the goals were achieved, most ­lower-income countries had healthier populations in 2015 than they had when the MDGs were launched in 2000.20 The success of the MDGs was the impetus to create a follow-up set of goals, called the Sustainable Development Goals (SDGs). Many of the MDG targets that were not reached are now included among the SDG targets along with a host of new targets and indicators covering a broader diversity of socioeconomic, health, and environmental issues (FIGURE 2–16).

36

Chapter 2 Global Health Priorities

MDGs

SDGs

8 goals 21 targets 60 indicators

17 goals 169 targets >230 indicators

1 Poverty & hunger 2 Education 3 Gender equality

1 Poverty 2 Hunger 4 Education 5 Gender equality 8 Work 10 Inequality 16 Peace

4 Child mortality 5 Maternal health

3 Health

6 Infectious diseases 7 Environmental sustainability

6 Water & sanitation 7 Energy 9 Industry 11 Cities 12 Sustainability 13 Climate 14 Sea 15 Land

8 Global partnership

17 Global partnership

FIGURE 2–16  Transitioning from the MDGs to the SDGs.

▸▸

2.5 Sustainable Development Goals

The Sustainable Development Goals (SDGs) are 17 goals established by the member countries of the United Nations at the end of 2015 that aim, by 2030, to end poverty, protect the planet, and promote prosperity and peace (FIGURE 2–17).23 The 17 SDGs are operationalized through 169 targets and more than 230 indicators.24 The preamble of the 2030 Agenda for Sustainable Development that guides the SDG process states that the goals are “a plan of action for people, planet, and prosperity” that aim “to end poverty and hunger” in order to “ensure that all human beings can fulfill their potential in dignity and equality and in a healthy environment,”

“to protect the planet from degradation,” “to ensure that all human beings can enjoy prosperous and fulfilling lives,” and “to foster peaceful, just, and inclusive societies which are free from fear and violence.”23 Like the MDGs, the SDGs consider health to be both a necessary prerequisite to and an outcome of economic growth. Two of the 17 SDGs focus specifically on health (SDG 3) and nutrition (SDG 2). Several of the SDGs address the socioeconomic determinants of health: poverty (SDG 1), education (SDG 4), gender equality (SDG 5), employment (SDG 8), equal opportunities for all people (SDG 10), peace (SDG 16), and good governance (SDG 17). The remaining SDGs address the environmental determinants of health: water and s­ anitation (SDG 6), affordable clean energy (SDG 7), safe work environments (SDG 9), healthy urban areas (SDG 11), sustainable consumption and production practices (SDG 12), and healthy climates (SDG 13), including healthy oceans (SDG 14) and land (SDG 15). Unlike the MDGs, the SDGs are not singularly focused on the world’s poorest billion people. While the SDGs remain “focused in particular on the needs of the poorest and most vulnerable,” the SDGs mix goals for poverty reduction with a lengthy list of other targets that apply to countries across the economic spectrum, noting that “if we realize our ambitions across the full extent of the Agenda, the lives of all will be profoundly improved and our world will be transformed for the better.”23 The goal is to improve “the lives of all” and not just some countries and some stakeholders. For example, although there is only one SDG focused specifically on health, SDG 3 includes a much greater diversity of targets and indicators than were encompassed by the three MDGs that aimed to reduce the burden from child mortality, maternal mortality, and infectious diseases (primarily HIV, malaria,

2.5  Sustainable Development Goals

SDG

Theme

Goal

1

No poverty

End poverty in all its forms everywhere

2

Zero hunger

End hunger, achieve food security and improved nutrition, and promote sustainable agriculture

3

Good health and well-being

Ensure healthy lives and promote well-being for all at all ages

4

Quality education

Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all

5

Gender equality

Achieve gender equality and empower all women and girls

6

Clean water and sanitation

Ensure availability and sustainable management of water and sanitation for all

7

Affordable and clean energy

Ensure access to affordable, reliable, sustainable, and modern energy for all

8

Decent work and economic growth

Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all

9

Industry, innovation, and infrastructure

Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation

10

Reduced inequalities

Reduce inequality within and among countries

11

Sustainable cities and communities

Make cities and human settlements inclusive, safe, resilient, and sustainable

12

Responsible consumption and production

Ensure sustainable consumption and production practices

13

Climate action

Take urgent action to combat climate change and its impacts

14

Life below water

Conserve and sustainably use oceans, seas, and marine resources for sustainable development

15

Life on land

Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss

16

Peace, justice, and strong institutions

Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels

17

Partnership for the goals

Strengthen the means of implementation and revitalize the global partnership for sustainable development

FIGURE 2–17  Sustainable Development Goals (SDGs) (2016–2030). Reproduced from United Nations. Transforming our world: The 2030 agenda for sustainable development. New York: UN; 2015, p. 14.

37

38

Chapter 2 Global Health Priorities

and tuberculosis). The health-focused SDG targets include ambitious aims for further reducing maternal and child mortality, alleviating the burden from a diversity of infectious diseases (including hepatitis B virus and neglected tropical diseases), reducing the number of adults who die before their 70th birthdays from common NCDs (cardiovascular disease, cancer, diabetes, and chronic respiratory diseases), improving treatment of substance use disorders and other mental health conditions, preventing ­transportation-related deaths, and

Target

Theme

increasing the accessibility of health services, medications, and vaccines (FIGURE 2–18).25 Because all of these health conditions and the socioeconomic and environmental conditions that influence them are now among the priorities for global action for the next decade, the SDGs are deployed as a framework for the outline of this book. The links between all of the SDGs and health are described in the next two chapters (FIGURE 2–19). The specific health topics and conditions included among the SDG targets are described in the remaining chapters (FIGURE 2–20).

Target

Theme

2.2

Child nutrition

3.8

Universal health coverage

3.1

Maternal mortality

3.9

Mortality due to air pollution

3.2

Child mortality

3.9

3.3

HIV

Mortality due to unsafe water and sanitation

3.3

Tuberculosis

3.9

Mortality due to unintentional poisoning

3.3

Malaria

3.a

Tobacco use

3.3

Hepatitis

3.b

3.3

Neglected tropical diseases

Access to essential medicines and vaccines

3.4

Noncommunicable diseases

3.c

Health workers

3.4

Suicide

3.d

Emergency preparedness

3.5

Substance abuse

6.1

Drinking water

3.6

Road traffic injuries

6.2

Sanitation

3.7

Sexual and reproductive health

7.1

Clean household energy

16.1

Homicide

11.6

Air pollution

16.1

Conflicts

13.1

Natural disasters

FIGURE 2–18  Examples of Sustainable Development Goals targets related to health. Data from World health statistics 2016: monitoring health for the SDGs. Geneva: WHO; 2016.

39

2.5  Sustainable Development Goals

SDG

Theme

Section

1

No poverty

3.2

4

Quality education

3.3

5

Gender equality

3.4

8

Decent work

3.5

10

Reduced inequalities

3.6, 3.7

16

Peace and good governance

3.8

6

Clean water and sanitation

4.2

7

Affordable and clean energy

4.3

9

Industry and infrastructure

4.4

11

Sustainable cities

4.5

12

Responsible consumption and production

4.6

13

Climate action

4.7

FIGURE 2–19  Where in this book to find information about the Sustainable Development Goals as determinants of health.

SDG Target

Theme

Chapter

(Many)

Socioeconomic determinants of health

3

(Many)

Environmental determinants of health

4

3.c

Health workforce

5

3.b

Access to affordable medicines and vaccines

5

3.b

Official development assistance for health

6

3.d

Health emergency preparedness

7 (continues)

40

Chapter 2 Global Health Priorities

SDG Target

Theme

3.3

HIV

8

3.3

Tuberculosis

8

3.2

Child mortality

9

3.3

Hepatitis

9

3.3

Malaria

10

3.3

Neglected tropical diseases

10

3.7

Sexual and reproductive health

11

3.1

Maternal mortality

11

2.1, 2.2

Nutrition

12

Cancer

13

Cardiovascular disease

14

Diabetes and chronic respiratory diseases

15

3.a

Tobacco use

15

3.5

Substance abuse

16

3.4

Suicide

16

3.6

Road traffic injuries

17

16.1

Violence

17

(Many)

Child health

18

(Many)

Adult health

19

3.4

Chapter

FIGURE 2–20  Where in this book to find information about the health issues featured as Sustainable Development Goals targets.

References

▸▸

References

1. Ten great public health achievements: United States, 1990–1999. MMWR Morb Mort Wkly Rev 1999; 48:241–3. 2. Ten great public health achievements: worldwide, 2001–2010. MMWR Morb Mort Wkly Rev 2011; 60:814–8. 3. Yazbeck AS. An idiot’s guide to prioritization in the health sector. Washington DC: World Bank; 2002. 4. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1649–724. 5. Glassman A, Chalkidou K, editors. Priority-setting in health: Building institutions for smarter public spending. Washington DC: Center for Global Development; 2012. 6. The case for investing in public health: A public health summary report for EPHO 8. Copenhagen: WHO Regional Office for Europe; 2014. 7. Pathways to global health research: Strategic plan 2008–2012. Bethesda MD: The John E. Fogarty International Center, National Institutes of Health (NIH); 2008. 8. Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA. Grand challenge in global health. Science. 2003;302:398–9. 9. Convention on the Rights of the Child. New York: United Nations; 1989. 10. Koplan JP, Fleming DW. Current and future public health challenges. JAMA. 2000;284:1696–8. 11. Murray CJ, Frenk J. Health metrics and evaluation: Strengthening the science. Lancet. 2008;371:1191–9. 12. AbouZahr C, Boerma T. Health information systems: The foundations of public health. Bull World Health Organ. 2005;83:578–83. 13. UN Department of Economic and Social Affairs. World population prospects: The 2017 revision. New York: UN; 2017. 14. GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life years

41

(DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1603–58. 15. Chen A, Jacobsen KH, Deshmukh AA, Cantor SB. The evolution of the disability-adjusted life year (DALY). Socioecon Plann Sci. 2015;49:10–15. 16. Prüss-Üstün A, Mathers C, Corvalán C, Woodward A. Assessing the environmental burden of disease at national and local levels: Introduction and methods. Geneva: WHO; 2003. 17. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602. 18. Gold MR, Stevenson D, Fryback DG. HALYs and QALYs and DALYs, oh my: Similarities and differences in summary measures of population health. Annu Rev Public Health. 2002;23:115–34. 19. Sassi F. Calculating QALYs, comparing QALY and DALY calculations. Health Policy Plan. 2006;21;402–8. 20. The Millennium Development Goals report 2015. New York: United Nations; 2015. 21. Waage J, Banerji R, Campbell O, et al. The Millennium Development Goals: A cross-sectoral analysis and principles for goal setting after 2015. Lancet. 2010;376:991–1023. 22. Health in 2015: From MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals. Geneva: WHO; 2015. 23. United Nations. Transforming our world: The 2030 Agenda for Sustainable Development. New York: UN; 2015. 24. Tier classification for global SDG indicators (20 April 2017). New York: Inter-agency Expert Group on SDG Indicators (IAEG-SDGs); 2017. 25. United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2 /Rev.1). New York: UN; 2016.

© Xinzheng. All Rights Reserved/Moment/Getty

CHAPTER 3

Socioeconomic Determinants of Health The disparities in health status between populations are largely due to gaps in economic development rather than differences in biology. People tend to have worse health profiles when they are poor, have low levels of education, are unemployed, experience discrimination, and have limited opportunities to participate in social and political processes. Increases in socioeconomic status are associated with improved health status, and better health enables further advancement in quality of life for individuals and communities.

▸▸

3.1  Health Disparities and the SDGs

Socioeconomic status (SES), also called socioeconomic position (SEP), describes an individual’s standing in a society based on individual and household income, education, gender, occupation, ethnicity and race, and other characteristics that exist within a broader cultural, social, political, and policy environment.1 There is no one measure of SES, but proxies, such as ownership of various assets (like a house, car, bicycle, television, radio, or livestock), amount and type of education, type of job, residential area, and other characteristics, can be used to evaluate a person’s relative position in a community or larger population group. These socioeconomic characteristics have a significant impact on an individual’s health status and ability to 42

access healthcare services. The personal factors and community conditions that enable or hinder access to health are collectively called the social determinants of health.2 Many of these social determinants of health can be summarized using the acronym PROGRESS: place of residence, race and ethnicity, occupation and employment status, gender and sex, religion, education, social capital, and other socioeconomic indicators (FIGURE 3–1).3 Children and adults who have low SES, in terms of either absolute poverty or relative poverty compared to their neighbors, tend to have significantly reduced health status compared to people from wealthier socioeconomic groups.4 The reduced health status in populations with lower SES is largely a function of economic, social, and political environments, and it is not caused by innate biological differences. An avoidable difference in health status between population groups is called a

3.1  Health Disparities and the SDGs

P

Place of residence (rural/urban; particular state or province; housing characteristics)

R

Race, ethnicity, culture, and language

O

Occupation and employment status

G

Gender and sex

R

Religion

E

Education

S

Socioeconomic position (income, wealth, and other measures)

S

Social capital (neighborhood, community, and family support and other aspects of social relationships and networks)

Plus

Age, disability, sexual orientation, and other characteristics

43

FIGURE 3–1  The PROGRESS-Plus framework for the social determinants of health. Data from Kavanagh J, Oliver S, Lorenc T. Reflections on developing and using PROGRESS-Plus. Equity Update 2008;2:1–3.

health disparity or an inequality.5 When a health inequality is considered to be unfair and unjust, the difference is classified as an ­inequity.6 Social justice is the principle that moving toward greater equality in the distribution of income and wealth, opportunities for education and employment, access to health and security, and involvement in civic and political activities is valuable for human flourishing.7 One of the key goals of global public health is to reduce health disparities by increasing the health status of disadvantaged populations.8 (Reducing health disparities by reducing the health status of the advantaged population would not be a global health gain.) SES usually refers to individual characteristics. A related set of metrics can be used to compare the development status of different countries. The Human Development Index (HDI) is an estimate of national development calculated from composite data on longevity (life expectancy at birth), knowledge (such as the mean and expected years of schooling), and income (gross national income per capita

in purchasing power parity dollars).9 The HDI has increased in most countries over the past 25 years as life expectancies, school enrollment, and incomes have risen (FIGURE 3–2), but there are still significant gaps between the richest countries and the poorest countries (FIGURE 3–3).9 These disparities are evident in the health metrics from high-income and low-income countries. Objective measures of socioeconomic development in a country, such as the components of the HDI, generally align with subjective measures of quality of life reported by the country’s residents. A higher HDI is correlated with better health status and also with greater levels of happiness (FIGURE 3–4).10 Making progress toward achieving the socioeconomic Sustainable Development Goals (SDGs) of ending poverty (SDG 1), ensuring quality education for all (SDG 4), achieving gender equality (SDG 5), promoting employment and decent work for all (SDG 8), reducing inequalities within and among countries (SDG 10), and promoting peaceful societies and good governance

44

Chapter 3 Socioeconomic Determinants of Health

1.0

Human Development Index (HDI)

0.8

0.6

0.4

0.2

0.0 USA

Germany

Iran

Brazil

1990

2000

China

India

2010

Nigeria

Ethiopia

2015

Data are not available for Nigeria in 1990 and 2000 Data are not available for Ethiopia in 1990

FIGURE 3–2  The Human Development Index (HDI) is increasing as people live longer, spend more years in school, and earn more. Data from Human development report 2016. New York: UNDP; 2015.

(SDG 16) will improve the quality of life and the quality of health for billions of people.

▸▸

3.2 Economics

SDG 1 sets an ambitious goal of “ending poverty in all its forms everywhere.”11 Extreme poverty is defined as surviving on less income than an international poverty line, typically set at an income of less than $1 or $2 per person per day.12 Many of the world’s poorest people live in remote rural areas, where they try to grow enough as subsistence farmers with a small plot of land to feed all household members. Others are the urban poor, who often live in informal settlements that have no trash

© Sam DCruz/Shutterstock

removal, running water, electricity, or other utilities. The percentage of the world’s people living in extreme poverty decreased from approximately 35% in 1990 to 10% in 2015,

3.2 Economics

45

Missing/Excluded Less then 0.5 0.5 to 0.65 0.65 to 0.75 0.75 to 0.85 0.85 and above

FIGURE 3–3  Human Development Index (2015). Data from Human development report 2016. New York: UNDP; 2015. 1= worst possible life 10 = best possible life 1

2

3

4

5

6

7

8

9 10

USA Germany Iran Brazil China India Nigeria Ethiopia low

high

FIGURE 3–4  A higher proportion of people in countries with higher HDIs report being happy. Data from Helliwell J, Layard R, Sachs J, editors. World happiness report 2017. New York: Sustainable Development Solutions Network; 2017.

and the SDGs aim to further reduce that percentage to 0% by 2030 (FIGURE 3–5).12 As of 2015, however, the majority of people in many low-income countries (the lowest of the four country income level groupings) were living below international thresholds for poverty (FIGURE 3–6). An even higher percentage of people are considered to live in relative

­ overty, living on less than the nationally p defined poverty line in their own countries. Poverty is about more than income and consumption. Economic factors are intertwined with a variety of sociocultural, political, and environmental conditions that enable some people to thrive and cause others to struggle. The United Nations Development Programme (UNDP) calculates a Multidimensional Poverty Index (MPI) that combines data regarding health (including hunger and child mortality), education (including total years of school for adults and enrollment of children in school), and standard of living (including access to electricity, drinking water, and toilets, whether the floors in the home are dirt or some other material, the type of cooking fuel used, and the presence of economic assets). When the MPI is used as a measure of poverty rather than income alone, a large proportion of people living in lower-income countries are classified as living in poverty (FIGURE 3–7).9 Poverty is not uniformly distributed within low-income countries, and there are often substantial variations in the poverty rate within

Chapter 3 Socioeconomic Determinants of Health

50

9 8

tion

ec Proj

Number of people (in billions)

7

40

6 30

5 4

20

3 2

10

Go

% living in extreme poverty

46

al

1 0 1980

1990

2000

2010

2020

0 2030

Number of people who are not living on $3.10 per day

60%

$1.91 to $3.09 per day

40%

< $1.90 per day 20%

0% (2013)

(2013)

(2013)

(2013)

(2010)

(2011)

(2009)

(2010)

USA

Germany

Iran

Brazil

China

India

Nigeria

Ethiopia

FIGURE 3–6  A large proportion of residents of lower-income countries live in poverty. Data from World development indicators 2016. Washington: World Bank; 2016.

national borders. For example, in Nigeria the proportion of people with an MPI indicating poverty or severe poverty is higher in rural areas than in cities and is much higher in the north than in the south.13 No matter where they are located, people living in poverty may have limited opportunities for education and employment, limited participation in social

and cultural activities, and limited engagement in civic and political processes.14 Poverty is also inextricably tied to health: living in poverty causes ill health, and ill health can cause poverty. Similarly, economic growth facilitates improvements in population health status, and investments in public health stimulate economic growth.15

3.2 Economics

100% 80% 60% 40% 20% 0% (2013) (2012) (2006) (2013) (2011) Brazil China

India Nigeria Ethiopia

Not poor Near poverty (MPI 20-33.2) Poverty (MPI 33.3-49.9) Severe poverty (MPI > 50)

FIGURE 3–7  The Multidimensional Poverty Index (MPI). Data from Human development report 2016: Work for human development. New York: UNDP; 2016.

The economic status of a household is a function of both income and wealth. Income is the amount of take-home pay earned by household members in a week, year, or other time period. Wealth is the accumulated worth of the household’s resources and can include a house, car, television or radio, livestock, and other consumer goods. When someone in a high-income or wealthy household has a health concern, that person usually has the resources to immediately access high-quality medical care, accurate diagnostic tests, and effective therapies. Attending to health issues early usually prevents mild issues from becoming severe problems. By contrast, low-income households generally have very little wealth, so they have few resources to draw on when someone in the household develops a severe illness or is seriously injured. People living in low-resource households may not be able to afford to seek care for health problems that are not immediately life-threatening or disabling. The direct costs of medical care add up quickly when they include transportation to a healthcare facility, fees for clinical consultations,

47

and payment for medications and supplies like bandages (which often are not provided by healthcare facilities and must be purchased by the patient). There are also indirect costs associated with lost wages for patients and caregivers, especially when outpatients must sit in a waiting area for a full day before seeing a clinician and when families of hospitalized patients must provide all food and most personal care for inpatients. The facilities where poor people can access health services are often underfunded, understaffed, and understocked, and they rarely have the clinical specialists, support staff, and equipment necessary to be able to offer advanced care.16 These disparities in access to health services contribute to the significant gaps in health status between the average person from a high-income household and the average person living in a low-income household. Just as the health status of individuals and families is related to their SES, the health status of communities and nations is linked to their economic status. Health economists use a variety of macroeconomic indicators to measure the amount of economic activity in a country. To distinguish between these measures, consider the way the GNI, GDP, and GNP of G ­ ermany would be calculated. The gross national income (GNI) is the total income from the selling of goods and services produced in Germany, including consumer spending, government spending, investments, and exports. The gross domestic product (GDP) is the total amount of goods and services produced in Germany by both German and foreign companies. The gross national product (GNP) is the total amount of goods and services produced by German companies in Germany and by German companies operating in other countries. All three of these metrics can be recorded in per capita (per person) terms by dividing the total monetary value by the population of the country. It is impossible to accurately measure all economic transactions in a country, so macroeconomic metrics are estimated using the best available data. There are a variety of methods that can be used for the estimation process. The World Bank often uses an “Atlas method” to estimate

48

Chapter 3 Socioeconomic Determinants of Health

the GNI. The Atlas method calculates the GNI by adding together the value of product sales and taxes (minus subsidies) within the country plus salaries and property income from abroad and then adjusting the total to account for inflation.12 Because the amount of goods and services that can be purchased with a given amount of money varies from place to place—for example, it costs less to rent an apartment in Addis Ababa than to rent an apartment in New York City—it can be helpful for economic indicators to account for cost of living differences. GNI can be estimated in terms of purchasing power parity (PPP), which adjusts the economic metric based on how many goods, services, and other products can be purchased in each country with a fixed amount of money, such as $1000 U.S. dollars. A clever example of PPP is the “Big Mac Index” that determines the relative price of a McDonald’s hamburger in different countries and uses that exchange rate to determine the relative value of other items.17 If a Big Mac costs $4 in one country and $2 in another, it is likely that the cost of living is about

twice as high in the $4-per-hamburger country. Workers in the higher-priced country will have to earn a much higher salary to stay above the local poverty line than workers in the $2-per-burger country. In high-income countries, the Atlas and PPP methods generate similar values for the GNI, but in low- and middle-­income countries (LMICs), the PPP GNI is usually much higher than the Atlas GNI (FIGURE 3–8).18 Summary values like the GNI have some major limitations as indicators of development. They do not count unpaid labor like caring for children and growing food to feed a family. They ignore issues of sustainability, environmental damage, and the distribution of wealth in a country. These values show the economic experience of the “average” person living in each country, but the “average” economic measure may be misleading if most people in a given country are very poor and some are extremely rich and there is almost no middle class. Even when a large proportion of the population experiences something near the average

GNI per capita: PPP method (in thousands)

90 80 70 60

USA GER

50

High income Upper middle income

40

Lower middle income Low income

30 20

IRAN

10 IND

BRA CHI NIG

ETH

0

10

20

30

40

50

60

70

80

90

GNI per capita: Atlas method (in thousands)

FIGURE 3–8  The GNI can be calculated in different ways, such as using an Atlas method or purchasing power parity (PPP). (The dots represent the 100 most populous countries.) Data from World development indicators 2016 (Table 2.1). Washington: World Bank; 2016.

3.2 Economics

reported for the country, there will still be variability in the experiences of individuals. There are millionaires in every country, even the countries with the poorest “average” person, and there are people in every country, even the wealthiest ones, who live on almost nothing.

49

However, at the population level, these metrics reveal important trends. For example, even small increases in the GNI per capita are associated with significant decreases in child mortality rates (FIGURE 3–9) and significant increases in life expectancy at birth (FIGURE 3–10).19

Under-5 mortality rate per 1000

160 140 120

NIG

100 80 ETH

60

IND

40

BRA IRAN

20

GER USA

CHI

0 100

10,000

1,000

10,0000

GNI per capita (Atlas method, logarithmic scale)

FIGURE 3–9  Small increases in GNI per capita in lower-income countries are associated with significant decreases in the rate of death for children between birth and their fifth birthdays. (The dots represent the 100 most populous countries. Note the use of the logarithmic scale on the x-axis.) Data from World development indicators 2016 (Table 2.21). Washington: World Bank; 2016. 100

Life expectancy at birth

90 GER

80

IRAN CHI

70

USA BRA

IND ETH

60 50

NIG

40 100

1,000

10,000

100,000

GNI per capita (Atlas method, logarithmic scale)

FIGURE 3–10  Small increases in GNI per capita in lower-income countries are associated with significant increases in life expectancy at birth. (The dots represent the 100 most populous countries. Note the use of the logarithmic scale on the x-axis.) Data from World development indicators 2016 (Table 2.21). Washington DC: World Bank; 2016.

Chapter 3 Socioeconomic Determinants of Health

60

100%

50

80%

% Share of income

Less equal

Highest 20%

40 60% 30 40%

Second highest 20%

Gini index

50

Middle 20% Second lowest 20% Lowest 20%

20 20%

Gini Index

10

0%

0 USA Germany Iran

Brazil

China

More equal

India Nigeria Ethiopia

FIGURE 3–11  The Gini Index and the percentage share of income by income quintile. In a completely equal country, each of the quintiles would have a 20% share of income. In countries with a higher Gini Index (more inequality), the richest people have a higher percentage of income. Data from World development indicators 2016 (Table 2.9). Washington: World Bank; 2016.

The Gini Index is a measure of the inequality in the distribution of incomes within a particular country. A country in which everyone has exactly the same income has an index of 0 (perfect equality) and a country in which one person has all the income and everyone else has zero income has an index of 100 (perfect inequality). Brazil has a Gini Index of about 40, and the richest 10% earn more than forty times more than the poorest 10%. Germany has a Gini Index of about 30, and the richest 10% earn about seven times more than the poorest 10%.20 However, the income level of a country is not a good predictor of Gini Index values (FIGURE 3–11).21 Some high-income countries have relatively unequal income distributions, and some low-income countries have relatively equal income distributions. When two countries have similar economic profiles, the country with greater income inequality tends to have a less favorable health profile.22 Because economic status is so strongly tied to health status, progress toward achieving

© punghi/Shutterstock

SDG 1 is necessary for sustained progress toward achieving the health-specific SDGs. The specific targets for ending poverty include eradicating extreme poverty, defined as living on less than $1.25 per day (SDG 1.1); reducing by half the proportion of people living in poverty according to national definitions (SDG 1.2); and implementing social protections for vulnerable populations, such as children, older adults, and people with disabilities (SDG 1.3).23

3.3 Education

▸▸

3.3 Education

Both the ability to read and a higher number of years of formal education are correlated with higher health status for adults and their children.24 SDG 4 aims to “ensure inclusive and equitable quality education and promote lifelong learning opportunities for all,” starting with access to early childhood education (SDG 4.2), and continuing with access for all girls and boys to primary and secondary education (SDG 4.1) and then to technical, vocational, or university education (SDG 4.3).11 Most high- and uppermiddle-­income countries have strong enrollment in early childhood education and primary education, but in most lower-income countries, there is limited access to preschool education, and many school-aged children do not attend primary or secondary school (FIGURE 3–12).25 Since many schools in lower-income countries have school health programs that provide hygiene and health education, nutritional support, treatment for common intestinal worm infections, and other health services, children who are not in school miss critical opportunities for both learning and healthy development.26 Literacy is the ability to read and write and apply those communication skills. Literacy exists along a spectrum from minimal recognition of written words to the advanced fluency gained through higher education. Functional literacy is the ability to understand written words well enough to complete normal daily tasks.27 Functional literacy allows readers to acquire health information, navigate health systems, and attain other benefits associated with health literacy, the ability to access, understand, and apply health information.28 Readers can learn about food preparation and exercise programs in newspapers and magazines, comprehend health and safety warnings on consumer products, access air and water quality reports, read posters advertising immunization and screening campaigns, follow directions on medicine containers and hospital discharge orders, understand the health benefits packages

51

100

80

60

40

20

0 Iran

Brazil China

India Nigeria Ethiopia

% of preschool-aged children enrolled in pre-primary education % of primary school-aged children attending school % of secondary school-aged adolescents attending school

FIGURE 3–12  Many children and adolescents in low- and middle-income countries are not enrolled in early childhood, primary, or secondary education (2014). Data from The state of the world’s children 2016: A fair chance for every child. New York: UNICEF; 2016.

offered by employers and the government, apply for aid and benefits, read brochures about their health conditions, use signs to navigate hospitals, and seek out additional information online or at libraries. People who cannot read will have difficulty with all of these health-related activities. They may delay seeking care for a health problem because they worry about being unable to complete paperwork at a doctor’s office or being ridiculed for not knowing how to read or write. They may have difficulty taking their prescribed medications properly if their healthcare providers have not fully explained dosage and timing and they cannot read the instructions on the label. They may not be able to read the safety information provided by a pharmacist or know when to return for a follow-up examination.

52

Chapter 3 Socioeconomic Determinants of Health

Adult literacy in most LMICs increased between 2000 and 2015, but literacy rates among men and women remain low in many lower-income countries (FIGURE 3–13).29 Female literacy and education are especially important for family and child health.30 Women with more formal schooling are more likely to give birth at a healthcare facility (FIGURE 3–14A), which means that both mothers and newborns have an improved likelihood of survival if there are complications during or after delivery. The children of women with more education are also more likely to receive preventive medical services, such as vaccines (FIGURE 3–14B), and to receive professional clinical care for illnesses. Because women who have several years

of formal education are equipped to access the information they need to keep their children healthy and nourished, their children are more likely to survive past their fifth birthdays (FIGURE 3–14C). Increasing the proportion of girls and boys worldwide who complete at least a basic education (typically about seven years of primary school) will generate significant longterm benefits for the economic status and quality of life of those individuals and their families and communities. Reaching the target that “all youth and a substantial proportion of adults, both men and women, achieve both literacy and numeracy” by 2030 (SDG 4.6)11 will also yield major benefits for the health and well-­being of those individuals’ future children. goal=100%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Male Female Male Female Male Female Male Female Male Female Male Female Iran

Brazil

China 2000

India 2010

Nigeria

Ethiopia

2015

FIGURE 3–13  Literacy rates among adults (aged 15+ years) have increased in LMICs, but in many countries women lag behind men. Data from Education for all 2000–2015: Achievements and challenges. Paris: United Nations Educational, Scientific and Cultural Organization (UNESCO); 2015.

53

3.3 Education

A

% of babies born at a healthcare facility India (2006)

Ethiopia (2011)

Nigeria (2013)

100

100

100

80

80

80

60

60

60

40

40

40

20

20

20

0

0

0 0

B

1-4

5-7

8-9 10-11 12+ years

0

1-6

7-12

0

13+ years

1-8

9-12

13+ years

% of toddlers (12-23 months) who have received all basic vaccinations India (2006)

Nigeria (2013)

Ethiopia (2011)

100

100

100

80

80

80

60

60

60

40

40

40

20

20

20

0

0 0

C

1-4

5-7

0 0

8-9 10-11 12+ years

1-6

7-12

0

13+ years

1-8

9-12

13+ years

Number of children who die before their 5th birthdays per 1000 live births India (2006)

Nigeria (2013)

Ethiopia (2011)

200

200

200

160

160

160

120

120

120

80

80

80

40

40

40 0

0

0 0

1-4

5-7

8-9 10-11 12+ years

0

1-6

7-12

13+ years

0

1-8

9-12

13+ years

FIGURE 3–14  Women with more years of education (x-axis) have more interactions with the healthcare system, and their children are more likely to survive. Data from National Family Health Survey (NFHS-3) 2005–2006. Mumbai: International Institute for Population Sciences (IIPS)/Macro International; 2007; Demographic and Health Survey 2013. Abuja: National Population Commission/ICF International; 2014; Demographic and Health Survey 2011. Addis Ababa: Central Statistical Agency/ICF International; 2012.

54

▸▸

Chapter 3 Socioeconomic Determinants of Health

3.4 Gender

When the HDI is calculated separately by sex, females often lag behind males. A Gender Development Index (GDI) that compares the values of the HDI for females and males has a value of 1 when males and females have equal HDI values. In higher-income countries, the GDI is often near 1, but in lower-income countries, there is often a significant gap between males and females (FIGURE 3–15).31 Women and girls face different health challenges than men and boys because of both biological characteristics related to sex and social structures related to gender.32 Sex refers to the biological classification of people as male or female based on genetics (such as the presence of XX or XY sex chromosomes) and reproductive anatomy. Males and females also have different body chemistry, hormones,

physiology, and brain function. These differences mean that men and women sometimes have different symptoms for the same disease and different prognoses and pathways to recovery. For example, men are more likely to have dramatic heart attacks with crushing chest pain, while women often have subtle symptoms like feeling more tired than normal. This difference is a key reason why heart disease in women has traditionally been underdiagnosed.33 There are many significant differences in the burden of disease from particular health conditions for females and males that must be considered when planning for and implementing health education and preventive, diagnostic, and therapeutic health services (FIGURE 3–16).34 Gender refers to social, cultural, and psychological aspects of being male or female, and gender is shaped by the sociocultural 1.0

0.8

0.8

0.6

0.6

0.4

0.4

0.2

0.2

HDI

GDI

1.0

0.0

0.0 USA Germany

Iran

Brazil

China

India

Nigeria Ethiopia

Female HDI Male HDI Gender Development Index (GDI)

FIGURE 3–15  The Human Development Index (HDI) for females lags behind the HDI for males in many l­ower-income countries (2015). Data from Human development report 2015: Work for human development. New York: UNDP; 2015.

3.5 Employment

FEMALES have a higher proportion of DALYs than males from… ■■ ■■ ■■ ■■ ■■

Iron-deficiency anemia Cancers of the reproductive system (such as breast cancer) Depressive disorders, anxiety disorders, and migraine headaches Musculoskeletal disorders (such as osteoarthritis and rheumatoid arthritis) Alzheimer’s disease and other dementias

55

MALES have a higher proportion of DALYs than females from… ■■ ■■ ■■ ■■ ■■ ■■ ■■

Tuberculosis Cancers of the lung, liver, stomach, and esophagus Cirrhosis and other chronic liver diseases Alcohol and drug use disorders Autism spectrum disorders Unintentional injuries (such as road traffic injuries and drowning) Intentional injuries (such as violence and self-harm)

FIGURE 3–16  Examples of differences in the disability-adjusted life years (DALYs) attributed to various health risks for females and males. Data from GBD Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602.

environment and experience in addition to biology. There is tremendous variability in the ways that individuals express their gender and in the ways that cultures define gender roles. Gender roles describe how a culture believes men and women should behave. For example, gender roles may indicate what tasks women are expected to do, such as cooking, cleaning, and taking care of children. They may also define what tasks women should not do, which might include working with heavy machinery or serving as religious leaders. Some cultures consider women to be under the authority of their fathers or other male relatives until marriage and under the authority of their husbands after marriage. In these places, laws may restrict women’s ability to own property or manage their own finances. Some cultures have strict rules about what women can wear in public and whether they can be in public spaces unaccompanied by a male. This can limit the ability of women to participate in the marketplace and government, attend school and religious meetings, and acquire medical attention and information. Gender roles also define the social and behavioral norms for men. For example, young men may feel pressure to engage in risky behaviors like reckless driving or tobacco use in order to demonstrate their

masculinity. Men may also be expected to take on hazardous jobs.35 SDG 5 aims to “achieve gender equality and empower all women and girls.” The particular targets include eliminating “all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation” (SDG 5.2) and ending harmful practices “such as child, early, and forced marriage and female genital mutilation” (SGD 5.3).11 Achieving gender equity will require identifying and addressing the numerous preventable health issues that disproportionately affect women and girls and, at the same time, addressing the avoidable health conditions that disproportionately burden men and boys. Ideally, integrating gender-equity perspectives into new health policies, strategies, and plans will reduce within-country health disparities and improve overall population health status.36

▸▸

3.5 Employment

Employment of at least one wage earner per household is generally critical for keeping a household out of poverty. In addition to the

56

Chapter 3 Socioeconomic Determinants of Health

monetary income from working, employment often provides healthcare coverage, compensation for on-the-job injuries, and sometimes housing, food allowances, and schooling for employees and their children. These benefits can have a significant, positive impact on the health of workers and their families. SDG 8 aims to “promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all.”11 Decent work for all means eradicating forced labor and ending child labor (SDG 8.7) as well as protecting labor rights and promoting safe working environments (SDG 8.8). Unemployment occurs when a person who is not working for pay is unable to secure a position despite actively seeking a paid job. People who are retired, have opted not to work outside the home, or are not seeking employment for other reasons are not considered to be unemployed. ­Underemployment occurs when a person is involuntarily working part-time rather than full-time or is a lowwage worker whose earnings are below the local poverty level even after working long hours.37 (In this usage, underemployment does not refer to people who are employed fulltime and earning a living wage but who are underutilizing their education and training in their current positions.) Being unemployed or underemployed can be detrimental to mental and physical health status,38 and so can precarious employment conditions.39 People who have lost their jobs are more likely than working peers to develop depression and other mental health disorders.40 Suicide rates are higher among people who are unemployed.41 Unemployed people are more like to adopt unhealthy behaviors like smoking and harmful use of alcohol.42 All-cause mortality rates are higher among unemployed men and women than employed people of the same age.43 Not all jobs are equally beneficial for health. People working as manual laborers have higher all-cause mortality rates, cardiovascular mortality rates, and cancer mortality rates than people of the same age who are

working in nonmanual professional jobs.44 Men and women who work in manual jobs also report lower self-rated health than sameage peers who work as managers or in other professional positions.45 Among people doing manual labor, unskilled workers have higher mortality rates and lower self-rated health than skilled workers. People with limited job skills often have the most dangerous jobs, receive little compensation for their labor, and have little or no job security. Low-skilled workers who are injured or ill may not receive adequate treatment for their health problems when they cannot afford to take time off to consult with a medical professional and recuperate at home or they cannot afford to pay for health care. Three of the key components that contribute to the SES of an individual or household—employment and occupational category, economic security, and educational level—are inextricably linked to each other and to health status (FIGURE 3–17). Any

© Ari N/Shutterstock

Education/ literacy

Employment/ occupation HEALTH

Income/ wealth

FIGURE 3–17  Employment, economics, and e­ ducation are interrelated.

3.6  Minority Populations

intervention aimed at one of these three categories may positively impact the others. For example, new reading skills may lead to a better job, increased job skills may lead to a higher hourly wage, and extra income may be used to pay for additional training. An improvement in any one of these dimensions of SES can lead to increased health.

▸▸

3.6 Minority Populations

Major differences in health status exist between countries and also between different population groups within countries.5 Some of these health disparities are a product of differences in SES, and some are a function of prejudice and discrimination against people from particular groups.46 Prejudice is a perception about an individual based solely on preconceived notions about a sociocultural group to which that person belongs. Common forms of prejudice include racism, sexism, classism, ageism, and ableism (prejudice against people with disabilities). Discrimination encompasses the actions taken against an individual because of that person’s membership in a sociocultural group. Unfair hiring and pay practices, restrictions on access to housing, and harassing jokes and insults are examples of discriminatory practices. Prejudice is a set of beliefs and attitudes. Discrimination is a set of practices and behaviors. Prejudiced thoughts lead to discrimination, but not all people who hold prejudicial beliefs act on them. Culture is a way of living, believing, behaving, communicating, and understanding the world that is shared by members of a social unit. Culture encompasses a group’s norms, values, morals, rules, and customs as well as the foods people eat, the clothes they wear, the language they use, the ways they interact with those inside and outside the cultural group, and how they describe and experience illness (how a person perceives his or her

57

own experience of having an adverse health condition) and sickness (how a person with poor physical or mental health relates to and is regarded by the community).47 Culture plays a role in how health and disease are experienced across the life span, from the way childbirth is approached to decisions about end-of-life care. Culture influences health beliefs, affects health behaviors, and shapes decisions about when and where to seek healthcare services. Different cultures may have distinct explanations about what causes disease. A mechanistic approach views disease as a dysfunction or breakdown of the human body, which is expected to function like a well-oiled machine. A moralistic perspective considers health to be the result of clean living and disease to be a type of punishment for wrongdoing. A supernatural viewpoint blames illness on demonic possession, evil eye, or the anger of God or the gods or ancestors. A disequilibrium approach considers disease to be caused by imbalances within the body, such as an imbalance between hot and cold, yin and yang, or the four humors. Disease may also be attributed to energy or qi imbalances; to emotions like fright or grief or jealously; or to stress, weather, food, germs, sex, genes, or age. These beliefs about health and illness may influence the way people interpret symptoms and diagnoses, the timeline for seeking treatment, the type of healer who is consulted (such as a physician or nurse, a counselor, a religious advisor, a massage therapist, or an acupuncturist), and the type of ­therapy that will be effective. Celebrations of the various cultural traditions that exist within a nation or community can bring together people with diverse backgrounds. However, these differences can also be used to divide people. At worst, these divisions can lead to abuse, violence, hate crimes, war, and genocide. On a day-to-day basis, people who belong to minority racial, ethnic, tribal, or religious groups may encounter prejudice and discrimination along with language, cultural, and belief barriers. These obstacles may exist in the workplace and marketplace,

58

Chapter 3 Socioeconomic Determinants of Health

and they may also be present within the healthcare system. Medical practitioners may be unfamiliar with the special health needs of patients from other backgrounds, in part because many population groups remain understudied by health researchers. Patients may be uncomfortable discussing health concerns and being examined by a medical professional who is not a member of their group or who is not sensitive to their cultural beliefs and practices. For example, women from some cultural and religious groups may be unwilling to be examined by a male clinician. Some barriers to healthcare access are legally sanctioned, such as when proof of legal residency is required before health care can be offered. Because of these obstacles to accessing health care, the health status of minority populations tends to be worse than that of majority populations. Prejudice and discrimination are often related to race and ethnicity. Ethnicity is a social grouping based on many dimensions of cultural heritage, nationality, language, religion, tribal affiliation, and other factors. Race refers to superficial categories that group individuals based primarily on physical attributes like skin color. Significant cultural and genetic diversity is present within most racial groups. For example, the U.S. government typically collects and reports data for five racial categories and one ethnic category.48 The five racial categories are American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, and White. The “Asian” category groups people with ancestors from countries as diverse as China, India, the Philippines, and Thailand. The “White” category includes most people whose ancestors were Europeans, North Africans, or Middle Easterners, and many with ancestors from other countries in the Americas. The only ethnic category classifies people as “Hispanic or Latino” versus “Not Hispanic or Latino.” People who identify as “Hispanic or Latino” might have ancestry in places as diverse as Cuba, Ecuador, Mexico, and Spain.

Significant differences in health status often exist between different racial and ethnic groups. An assortment of explanations each partly explains the reasons for these health disparities.49 Racial and ethnic categories may capture some genetic differences between population groups, including some differential risks for heritable genetic disorders. Ethnicity may be a marker for some health-related behaviors. If members of a population group tend to have similar dietary preferences and favorite foods, alcohol and tobacco use habits, and physical activity routines, these practices may account for some of the health differences observed between populations. Race and ethnicity may also be associated with socioeconomic factors. Members of marginalized population groups may have lower SES than other people in their town or city, and poverty is known to be associated with reduced health status. Additionally, discrimination because of race or ethnicity (or other characteristics) may cause chronic psychosocial stress that contributes to poor health outcomes.50 Members of indigenous communities tend to have especially low health status compared to other residents of their countries. About 370 million people worldwide identify as members of indigenous population groups that have maintained unique cultural traditions (and often also languages) for many generations after the colonization or domination of their traditional homeland by another group.51 These populations include, among many others, the Cherokee and Navajo (and many other groups) of the United States, the Sami of Scandinavia, the Torres Strait Islanders of Australia, the Tangata Whenua (Māori) of New Zealand, the Quichua of Ecuador, the Maasai of Kenya, and the Hmong of Southeast Asia.52 Members of indigenous people groups are more likely to be poor than their nonindigenous neighbors, and they usually have higher rates of morbidity and premature mortality.53 SDG 10 aims to “reduce inequality within and among countries” by taking steps to reduce poverty (SDG 10.1), ensure equal opportunities

3.7  Migrant and Refugee Health

© Knumina Studios/Shutterstock

through the elimination of discriminatory laws (SDG 10.3), and “empower and promote the social, economic, and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion, or economic or other status” (SDG 10.2).11 Actions to increase equity across these domains are expected to reduce health disparities by increasing the health status of currently disadvantaged groups.

▸▸

3.7  Migrant and Refugee Health

A migrant is a person who has moved across an international border and has taken up residence in the new country.54 By 2015, there were nearly 250 million people worldwide who were living in a country that was not their original homeland.55 Some migrants intend to settle permanently in their new host country, while others are temporary residents or guest workers. An immigrant is a person who has

59

settled in a new country and intends to stay there permanently. A person who is temporarily living in another country and intends to return to his or her home country is called an expatriate. For example, people working in a foreign country for their home government, a business, the press corps, a nongovernmental organization, or another entity are usually considered to be “expats” rather than immigrants. Most migrants voluntarily move from one country to another to be closer to family, start a new job, or pursue educational opportunities. The majority of international migrants have moved from middle-income countries to high-income destination countries where their prospects for economic prosperity are greater (FIGURE 3–18).55 However, not all migration is voluntary. Some migrants are forced to move because of violence, persecution, or natural disasters. Some are involved in trafficking, which occurs when a migrant is forced into sex work, debt bondage, slavery, or other types of forced labor by the people who arranged the relocation. The experience of being an involuntary migrant is often accompanied by adverse health effects.56 Smuggled migrants, victims of trafficking, and people fleeing conflict and persecution may experience violence and nutritional deprivation as well as other traumas during their travels. While some migrants gain greater access to healthcare services when they move from a country with poor health infrastructure to a country with an easily accessible healthcare system, many migrants encounter new health challenges as they settle into their new places of residence.57 A refugee is a person who has been forced to move across an international border because of security concerns like war, civil conflict, political strife, or persecution based on race, tribe, religion, political affiliation, or membership in some other group. Refugees typically secure permission to move to a new country prior to arriving in that country. An asylum seeker is an involuntary migrant who asks for protection from a host country after

60

Chapter 3 Socioeconomic Determinants of Health

arriving in that country rather than waiting for a refugee application to be processed prior to traveling. Asylum seekers are often included in the refugee category in reports about involuntary international migration because the lived experiences of refugees and asylum seekers are similar. The primary difference between the groups is the status of their legal documents. To be classified as a refugee or asylum seeker, an involuntary migrant must cross an international border. Nearly all refugees and asylum seekers originate in LMICs, and most move to middle-income countries (FIGURE 3–19).58 An internally displaced person (IDP) is a person who fled his or her home community because of civil war, famine, natural disaster, or another crisis, but did not cross into another country and is, therefore, not afforded the same protection and assistance as a refugee.

In 2015, there were more than 21 million refugees and more than 3 million asylum seekers worldwide.58 Half of all refugees were less than 18 years old.58 The Office of the United Nations High Commissioner for Refugees (UNHCR) and other humanitarian

© Thomas Koch/Shutterstock

100%

100%

80%

80%

60%

60%

40%

40%

20%

20%

0%

0% Origination

Destination

Origination

Destination

Low-income countries

Low-income countries

Middle-income countries

Middle-income countries

High-income countries

High-income countries

FIGURE 3–18  Most migrants were born in middle-income countries and most move to highincome countries (2015).

FIGURE 3–19  Most refugees and asylum seekers were born in low- and middle-income countries and relocate to middle-income countries (2015).

Data from International migration report 2015. New York: UN Department of Economic and Social Affairs; 2016.

Data from Global trends: Forced displacement in 2015. Geneva: UNHCR; 2016.

3.8  Governance and Politics

organizations, both governmental and private, help provide for the basic needs of refugees, including water, food, sanitation, shelter, fuel, and health care for sick, pregnant, and vulnerable individuals. When possible, these organizations also offer treatment for malnutrition, address violence and security issues, and provide therapy for mental health problems, such as posttraumatic stress disorder. Fewer than half of refugees access these services in “camps” that provide long-term shelter. Most refugee camp residents are children, women, and the elderly. The rest are displaced to cities or rural areas, where they live alongside local residents (and other types of migrants) and rely on local social services for health care and other types of assistance.59 There were estimated to be about 28 million new IDPs worldwide in 2015, including about 8.6 million people displaced by conflict and violence and 19.2 million displaced by disasters.60 More than 40 million people worldwide had IDP status after adding new IDPs to those who had been displaced in previous years and had not yet found a permanent residence.60 IDPs and refugees share the experience of having lost their homes, jobs, social support networks, and some of their independence and sense of security. However, because IDPs have remained in their home countries, they are often not eligible for assistance from UNHCR and other international groups. IDPs usually do not live in camps. Most move to new rural areas or cities. The services provided to involuntary migrants early in the cycle of displacement are not intended to be long-term solutions. The ultimate goal is for involuntary migrants (and IDPs) to secure permanent living situations and become self-sufficient by integrating into their host countries, resettling in a new host country, or returning to their home communities. Refugees and IDPs who return to their home communities after a period of displacement may face challenges related to the destruction of homes, healthcare facilities, schools, and other community buildings; the loss of farmland to environmental damage

61

and to hazards like unexploded ordnance; and the displacement of their family members, neighbors, and other members of their community. Those who settle in new areas often face challenges associated with learning new cultural practices and adapting to them, overcoming language and communication barriers, having limited occupational options, and potentially having limited access to health care. ­Acculturation is the complex process of adopting the practices, traditions, values, and identity of a new community after migrating.61 Acculturation may be correlated with improved ability to navigate healthcare systems and access the tools for health. Several of the SDGs specifically address the well-being of migrants. One of the SDG targets for reducing inequality is to “facilitate the orderly, safe, regular, and responsible migration and mobility of people, including through the implementation of planned and well-­ managed migration policies” (SDG 10.7).11 Other SDG targets aim to protect migrants from being trafficked (SDG 5.2), forced into slavery (SDG 8.7), and working in unsafe environments (SDG 8.8). Policies and practices that address these issues and the other aspects of inequality covered by SDG 10 will improve the health of refugees and other migrants as well as the health of their neighbors.

▸▸

3.8  Governance and Politics

SDG 16 focuses on peace, justice, and strong institutions, and aims to “promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels.”11 The core of this goal is the need for good governance, the processes and structures that enable governments to set policies, provide services, and protect human rights. Good governance provides the policies, strategies, and resources that enable public agencies and other

62

Chapter 3 Socioeconomic Determinants of Health

organizations to be well managed, and sound management ensures that health and social services are reliably delivered to the people who need them. Countries with good governance have low rates of violence (SDG 16.1), child abuse and human trafficking (SDG 16.2), organized crime (SDG 16.3), corruption and bribery (SDG 16.4), and discrimination (SDG 16.b); they have freedom of the press (SDG 16.10); they have justice systems that quickly and fairly enforce laws (SDG 16.3); and they are transparent (SDG 16.6) and allow diverse representatives to participate in decision-making (SDG 16.7). None of the other SDGs can be achieved when functioning governance systems are not in place to ensure that everyone has access to health services, education, clean drinking water, and other tools for health. Access to health care and other services is associated with wealth, education, and employment, and it is also related to power. Power is the authority to control or influence the actions of others. Power can be conferred by political position and by socioeconomic advantages. Government officials may have the authority to demand certain services for themselves. Business leaders may have the money and connections to access care that is denied to others. Power can also be

conferred by cultural systems. A tribal or religious leader may have the power to mobilize people and resources at will. A husband may have the power to control his wife’s movements and activities. Powerful people can choose to limit or grant access to goods and resources like property, technology, social networks, and health care. Corruption occurs when politically powerful people abuse their positions for personal gain. LMICs tend to have less functional governance structures and more fraud, theft, bribery, kickbacks, and other types of corruption than high-income countries (FIGURE 3–20).62 In many countries, some people have the power to secure health for themselves and their families while others without power have limited or no access to the resources they need to be safe and healthy. Ethnic, racial, religious, and tribal minorities; immigrants, refugees, and internally displaced people; prisoners; people with mental health disorders or physical impairments; older persons; and members of other potentially vulnerable groups may not have the power to demand access to an equitable level of health care. An inclusive society is one in which all people have equitable access to governmental institutions and services, including health-related services.

Very 100 clean Corruption perception index

80

60 global average 40

20 Highly corrupt

0 USA

Germany

Iran

Brazil

China

India

Nigeria

Ethiopia

FIGURE 3–20  Low- and middle-income countries tend to have more corruption than high-income countries (2016). Data from Corruption perceptions index 2016. Berlin: Transparency International; 2017.

References

▸▸

References

1. WHO Commission on Social Determinants of Health. Health equity through action on the social determinants of health. Geneva: WHO; 2008. 2. Marmot M. Social determinants of health. Lancet. 2005;365:1099–104. 3. Kavanagh J, Oliver S, Lorenc T. Reflections on developing and using PROGRESS-Plus. Equity Update. 2008;2:1–3. 4. Wilkinson R, Marmot M. Social determinants of health: The solid facts. Copenhagen: WHO; 2003. 5. Braveman P, Tarimo E. Social inequalities in health within countries: Not only an issue for affluent nations. Soc Sci Med. 2002;54:1621–35. 6. Gwatkin DR. Health inequalities and the health of the poor: What do we know? What can we do? Bull World Health Organ. 2000;78:3–18. 7. Social justice in an open world: The role of the United Nations. New York: UN Department of Economic and Social Affairs; 2006. 8. Innov8 approach for reviewing national health programmes to leave no one behind: Technical handbook. Geneva: WHO; 2016. 9. Human development report 2015: Work for human development. New York: UNDP; 2015. 10. Helliwell J, Layard R, Sachs J, editors. World happiness report 2017. New York: Sustainable Development Solutions Network; 2017. 11. United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. New York: UN; 2015. 12. World development indicators 2016. Washington DC: World Bank; 2016. 13. National human development report 2015: Human security and human development in Nigeria. Abuja: UNDP Nigeria; 2015. 14. Report on the world social situation 2016: Leaving no one behind: The imperative of inclusive development. New York: UN Department of Economic and Social Affairs; 2016. 15. Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: A world converging within a generation. Lancet. 2013;382:1898–955. 16. Berendes S, Heywood P, Oliver S, Garner P. Quality of private and public ambulatory health care in low and middle income countries: Systematic review of comparative studies. PLoS Med. 2011;8:e1000433. 17. Ong LL. Burgernomics: The economics of the Big Mac standard. J Int Money Finance. 1997;16:865–78. 18. World development indicators 2016 (Table 2.1). Washington DC: World Bank; 2016. 19. World development indicators 2016 (Table 2.21). Washington DC: World Bank; 2016. 20. World development indicators 2016 (Table 2.9). Washington DC: World Bank; 2016.

63

21. World development indicators 2016 (Table 2.9). Washington DC: World Bank; 2016. 22. Wilkinson RG, Pickett KE. Income inequality and population health: A review and explanation of the evidence. Soc Sci Med. 2006;62:1768–84. 23. United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2/ Rev.1). New York: UN; 2016. 24. Kickbusch IS. Health literacy: Addressing the health and education divide. Health Promot Int. 2001;16:289–97. 25. The state of the world’s children 2016: A fair chance for every child. New York: UNICEF; 2016. 26. Bundy D, Schultz L, Sarr B. Platforms to reach school-age children (Chapter 20). Disease control priorities. 3rd ed. Child and adolescent health and development (Volume 8). Washington DC: IBRD/ World Bank; 2017. 27. Education for All (EFA) global monitoring report 2006: Literacy for life. Paris: United Nations Educational, Scientific and Cultural Organization (UNESCO); 2005. 28. Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000;15:259–67. 29. Education for All 2000–2015: Achievements and challenges. Paris: UNESCO; 2015. 30. King EH, Hill MA. Women’s education in developing countries: Barriers, benefits, and policies. Baltimore MD: Johns Hopkins University Press; 1993. 31. Human development report 2016. New York: UNDP; 2016. 32. Johnson JL, Greaves L, Repta R. Better science with sex and gender: Facilitating the use of a sex and gender-based analysis in health research. Int J Equity Health. 2009;8:14. 33. Arslanian-Engoren C, Engoren M. Physiological and anatomical bases for sex differences in pain and nausea as presenting symptoms of acute coronary syndromes. Heart Lung. 2010;39:386–93. 34. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602. 35. Gender equality, work and health: A review of the evidence. Geneva: WHO; 2006. 36. Integrating equity, gender, humans rights and social determinants into the work of WHO: Roadmap for action (2014–2019). Geneva: WHO; 2015. 37. Dooley D. Unemployment, underemployment, and mental health: Conceptualizing employment status as a continuum. Am J Community Psychol. 2003;32:9–20.

64

Chapter 3 Socioeconomic Determinants of Health

38. Wilson SH, Walker GM. Unemployment and health: A review. Public Health. 1993;107:153–62. 39. Benach J, Vives A, Amable M, Vanroelen C, Tarafa G, Muntaner C. Precarious employment: Understanding an emerging social determinant of health. Annu Rev Public Health. 2014;35:229–53. 40. Paul KI, Moser K. Unemployment impairs mental health: Meta-analyses. J Vocational Behav. 2019; 74:264–82. 41. Wanberg CR. The individual experience of unemployment. Annu Rev Psychol. 2012;63:369–96. 42. Dooley D, Fielding J, Levi L. Health and unemployment. Annu Rev Public Health. 1996;17:449–65. 43. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: A systematic review and metaanalysis of unemployment and all-cause mortality. Soc Sci Med. 2011;72:840–54. 44. Toch-Marquardt M, Menvielle G, Eikemo TA, et al. Occupational class inequalities in all-cause and cause-specific mortality among middle-aged men in 14 European populations during the early 2000s. PLoS One. 2014;9:e108072. 45. Aldabe B, Anderson R, Lyly-Yrjänäinen M, et al. Contribution of material, occupational, and psychosocial factors in the explanation of social inequalities in health in 28 countries in Europe. J Epidemiol Community Health. 2011;65:1123–31. 46. Stuber J, Meyer I, Link B. Stigma, prejudice, discrimination and health. Soc Sci Med. 2008;67:315–7. 47. Boyd KM. Disease, illness, sickness, health, healing and wholeness: Exploring some elusive concepts. Med Humanities. 2000;26:9–17. 48. Revisions to the standards for the classification of federal data on race and ethnicity. Washington DC: Office of Management and Budget (OMB); 1997. 49. Dressler WW, Oths KS, Gravlee CC. Race and ethnicity in public health research: Models to explain health disparities. Ann Rev Anthropol. 2005;34:231–52.

50. Pascoe EA, Smart Richman L. Perceived discrimination and health: A meta-analytic review. Psychol Bull. 2009;135:531–54. 51. Gracey M, King M. Indigenous health part 1: Determinants and disease patterns. Lancet. 2009;374:65–75. 52. Bartlett JG, Madariaga-Vignudo L, O’Neil JD, Kuhnlein HV. Identifying indigenous peoples for health research in a global context: A review of perspectives and challenges. Int J Circumpolar Health. 2007;66:287–307. 53. King M, Smith A, Gracey M. Indigenous health part 2: The underlying causes of the health gap. Lancet. 2009;374:76–85. 54. World migration report 2015. Geneva: International Organization for Migration (IOM); 2015. 55. International migration report 2015. New York: UN Department of Economic and Social Affairs; 2016. 56. International migration, health and human rights. Geneva: IOM; 2013. 57. Gushulak BD, MacPherson DW. The basic principles of migration health: Population mobility and gaps in disease prevalence. Emerg Themes Epidemiol. 2006;3:3. 58. Global trends: Forced displacement in 2015. Geneva: UNHCR; 2016. 59. Spiegel PB, Checchi F, Colombo S, Paik E. Health-care needs of people affected by conflict: Future trends and changing frameworks. Lancet. 2010;375:341–5. 60. Global report on internal displacement 2016. Geneva: Internal Displacement Monitoring Centre (IDMC), Norwegian Refugee Council; 2016. 61. Fox M, Thayer Z, Wadhwa PD. Assessment of acculturation in minority health research. Soc Sci Med. 2017;176:123–32. 62. Corruption perceptions index 2016. Berlin: Transparency International; 2017.

© Xinzheng. All Rights Reserved/Moment/Getty

CHAPTER 4

Environmental Determinants of Health Human health is dependent on clean water, clean air, and other features of a healthy environment. Households, workplaces, communities, and cities can take steps to promote sustainable access to utilities, prevent hazardous exposures to toxins, support ecosystem vitality, and build resilience to withstand natural disasters. Combatting climate change and other large-scale threats to planetary health requires global cooperation.

▸▸

4.1 Environmental Health and the SDGs

The most fundamental necessities for life are water, food, shelter, and fuel for heat and cooking. Where people live and work, the materials used to construct these buildings, what people eat and where that food comes from, the source and quality of drinking water, the quality of the air that is breathed, whether hazardous substances like cleaning agents, fertilizers, and motor oil are stored in or near the home, and numerous other components of the home environment play a role in health status. A broader set of environmental factors outside the home and workplace also contribute to health status, including geography, geology (such as the presence of earthquake fault lines or volcanoes), and climate (including whether the location is desert, tropical, arctic, or something more moderate, the types of vegetation and animals

that are native to the location, and the usual weather and temperature patterns in the area). Approximately 23% of deaths worldwide and 22% of disability-adjusted life years (DALYs) lost each year are attributable to water pollution, air pollution, occupational hazards, unsafe buildings and roads, and other modifiable environmental and occupational exposures (FIGURE 4–1).1 These burdens fall on both adults and children.2 Lack of access to safe drinking water, sanitation, and hygiene causes many cases of diarrheal diseases. Air pollution contributes to asthma, strokes, heart disease, respiratory infections, chronic obstructive pulmonary ­disease (COPD), and lung cancer. Failure to control insects and other pests enables the spread of malaria. The built environment contributes to the burden from drowning, road traffic accidents, falls, and other injuries. Occupational hazards cause low back pain and hearing loss. Numerous other factors contribute to other types of infections, noncommunicable diseases, and injuries (­FIGURE  4–2).1 65

66

Chapter 4 Environmental Determinants of Health

USA

Germany

Iran

Brazil

China

India

Nigeria

Ethiopia

Deaths

DALYs

FIGURE 4–1  About one in four deaths and one in five disability-adjusted life years (DALYs) lost worldwide are attributable to environmental exposures. Data from Prüss-Ustün A, Wolf J, Corvalán C, Bos, R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016.

Disease

Population Attributable Fraction (%)

Major Environmental Contributor(s)

Drowning

73

Safety of home and community environments, occupational risks

Diarrheal diseases

57

Water, sanitation, and hygiene

Asthma

44

Air pollution and occupational risks

Stroke

42

Air pollution

Malaria

42

Environmental vector management

Road traffic accidents

40

Occupational risks, built environment, traffic regulation, and land use

Ischemic heart disease

35

Air pollution

Acute lower respiratory infections

35

Air pollution

Chronic obstructive pulmonary disease

35

Air pollution and occupational risks

Falls

30

Built environment and occupational risks

Low back pain

26

Occupational risks

Hearing loss

22

Occupational noise

Self-harm

21

Chemicals, built environment, gun control, home and community safety

Cancers

20

Air pollution and many other factors

FIGURE 4–2  Percentage of disability-adjusted life years from selected conditions attributable to environmental risk factors. Data from Prüss-Ustün A, Wolf J Corvalán C, Bos, R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016.

4.2  Water, Sanitation, and Hygiene

Deaths

DALYs

(age standardized per 100,000 people)

(age standardized per 100,000 people)

350 300 250 200 150 100 50 0

67

20,000 15,000 10,000 5,000

ria Et hi op ia

ia

ig e N

In d

Ira n Br az il C hi na

an y

U

G

er m

SA

ria Et hi op ia

ia

ig e N

In d

il

hi na

C

Br az

Ira n

an y

U

G

er m

SA

0

FIGURE 4–3  The age-standardized rates of deaths and DALYs attributable to environmental risk factors are highest in lower-income countries. Data from Prüss-Ustün A, Wolf J, Corvalán C, Bos, R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016.

Public health requires safe home, work, and community environments. Public health is also dependent on healthy ecosystems at grander national, regional, and global scales. Poverty is often linked to unhealthy living and occupational environments. Poverty impacts the type of dwelling a household lives in (which can be unstable, unventilated, and built with harmful materials), how crowded the home is (which can facilitate the spread of infectious diseases like tuberculosis), and whether it is in proximity to schools, healthcare facilities, public transportation, and waste dumps. Many poor communities do not have consistently safe drinking water, toilets, or enough water to practice good hygiene, so the risk of contracting an infection is greatly increased. In some places, the dwindling availability of wood for fuel limits the ability of households to boil water and cook food. Without electricity for refrigeration, it is difficult to store food safely. In rural areas, the lack of infrastructure for communication and transportation makes it difficult to access health education and healthcare services. Furthermore, low-­income households may not have the money to purchase tools for disease prevention, because they must dedicate all income to immediate survival needs like food, housing, clothing, and emergency medical care. As a result of these challenges, environmental hazards place a particularly high burden on

residents of low- and middle-­income countries (FIGURE 4–3).3 One of the health-specific Sustainable Development Goals (SDGs) targets focuses specifically on environmental health, aiming to “substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution, and contamination” (SDG 3.9).4 Numerous additional SDG targets are related to environmental health (FIGURE 4–4), and making progress toward the environmental SDGs of ensuring drinking water and sanitation for all (SDG 6), ensuring modern energy for all (SDG 7), building resilient infrastructure (SDG 9), making cities safe and sustainable (SDG 11), ensuring responsible consumption and production patterns (SDG 12), and taking action to combat climate change and its impacts (SDG 12), along with the related goals of ocean conservation (SDG 14) and ecosystem restoration (SDG 15), will be necessary for achieving and maintaining poverty reductions and improvements in global health status.5

▸▸

4.2  Water, Sanitation, and Hygiene

Everyone needs access to an adequate daily supply of water for drinking, cooking, hygiene,

68

Chapter 4 Environmental Determinants of Health

1.5.3

Number of countries with national and local disaster risk reduction strategies

2.4.1

Proportion of agricultural area under productive and sustainable agriculture

3.9.1

Mortality rate attributable to household (indoor) and ambient (outdoor) air pollution

3.9.2

Mortality rate attributed to unsafe water, unsafe sanitation, and lack of hygiene

6.1.1

Percentage of the population using safely managed drinking water sources

6.2.1

Percentage of the population using safely managed sanitation services, including a handwashing facility with soap and water

6.3.1

Percentage of wastewater safely treated

6.b.1

Percentage of local administrative units with established and operational policies and procedures for participation of local communities in water and sanitation management

7.1.1

Percentage of the population with access to electricity

7.1.2

Percentage of the population with primary reliance on clean fuels and technology

7.2.1

Renewable energy share in the total final energy consumption

8.4.1 Material footprint, material footprint per capita, and material footprint per GDP 12.2.1 11.6.1

Proportion of urban solid waste regularly collected and with adequate final discharge out of total urban solid waste generated by cities

11.6.2

Annual mean levels of fine particulate matter in cities

12.4.1

Number of parties to international multilateral environmental agreements on hazardous and other chemicals and waste that meet their commitments and obligations

12.4.2

Hazardous waste generated per capita and proportion of hazardous waste treated

12.5.1

National recycling rate, tons of material recycled

12.7.1

Number of countries implementing sustainable public procurement policies and action plans

13.2.1

Number of countries that have communicated the establishment or operationalization of an integrated policy/strategy/plan that increases their ability to adapt to the adverse impacts of climate change

FIGURE 4–4  Examples of sustainable development goals targets related to environmental health. Data from United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2 /Rev.1). New York: UN; 2016.

4.2  Water, Sanitation, and Hygiene

and cleaning tasks, such as washing clothes, scrubbing cooking pots, and cleaning homes. Water access is a function of water quality, reliability, quantity, proximity, and cost.6 A household has access to safe drinking water when there is an adequate supply of affordable clean drinking water in or near the home (­FIGURE  4–5).6 The water needs to be free of bacteria, viruses, and parasites that can cause diarrhea and other infectious diseases, and it must also be free of harmful chemicals and sediments. The water should not appear cloudy, dirty, or strangely colored, so that it does not cause problems with cooking (such as giving food a strange flavor, color, or texture) or washing.7 To be classified as an improved

Service Level

Quality and Reliability

Quantity per Person per Day

69

water source, the water must be protected, which means that people should not wash clothes or bathe in the vicinity where drinking water is collected, and animals, sewage, and garbage should be kept away from the water source. The water source must be available and functioning all the time, or the household must have access to adequate water storage and water treatment methods, such as filtering, boiling, and using chemicals like chlorine. Hygiene is the practice of maintaining cleanliness in order to prevent disease. Personal hygiene behaviors include handwashing (hand hygiene), tooth brushing (oral hygiene), and bathing (body hygiene). Enough water must be available each day so people can stay hydrated

Proximity

Hygiene Needs Met?

Level of Health Concern

No access

Neither quantity nor quality ensured

May be less than 5 liters

More than 1 kilometer or 30 minutes round trip

No because only available at source

Very high

Basic access

Quantity ensured but quality not ensured

About 20 liters

Between 100 and 1000 meters or 5–30 minutes round trip

Yes for handwashing and food hygiene; no for laundry and bathing

High

Intermediate access

Quantity and quality usually assured

About 50 liters

Water delivered through one tap that is within 100 meters or 5 minutes round trip

Yes

Low

Optimal access

Quantity and quality ensured

About 100 liters

Continuous supply through multiple taps

Yes

Very low

FIGURE 4–5  Water service level (quality, reliability, quantity, and proximity) and health effects. Data from Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003.

70

Chapter 4 Environmental Determinants of Health

and clean. The average minimum amount of water needed by one person each day just in order to survive is about 15–20 liters (about 4–5 gallons): about 1–3 liters for drinking, 2–3 liters for food preparation and cleanup, 6–7 liters for personal cleanliness, and 4–6 liters for laundry.8 For healthy living, rather than mere survival, a minimum of about 50 liters (13 gallons) of water per person per day is recommended.6 (As a comparison, the typical American uses about 90 gallons daily at his or her residence for indoor and outdoor purposes.9) To be considered accessible, the water source must be close enough to the home so that distance does not prevent people from using the water they need for health. At best, water is piped directly into an individual house. Public water taps, boreholes, and protected (and lined) dug wells that bring water near to homes, but not inside them, are also considered to be improved water sources (­FIGURE  4–6).10 Ideally, every person should live within 1 kilometer (about 0.6 miles) of a safe drinking water source.6 When water sources are farther from the home, women and children may have to spend several hours each day walking to a water source, waiting for their turn to fill a container, and walking

home. In some places, it is possible for households to supplement their water access by collecting and storing rainwater for drinking and ­domestic use. Water must be affordable enough that people have access to at least the minimum amount of water necessary for healthy living. This does not mean that water must be free. Households using a community water system may be asked to pay a reasonable fee so that the system can be maintained. These fees also promote water conservation if they are tied to the amount of water drawn from the pump by a household. However, it is problematic for public health when public water supplies are

© punghi/Shutterstock

Improved

Unimproved • Surface water from a river, dam, lake, pond, stream, canal, irrigation channel, or other water body

• Unprotected dug well

• Public tap or standpipe

• Unprotected spring

• Tube well or borehole

• Water from mobile vendors, such as tanker trucks or carts with a small tank or drum • Bottled water (when used as a primary source of water)

• Piped water into the user’s home or yard

• Protected dug well • Protected spring • Rainwater collection

FIGURE 4–6  Examples of improved and unimproved drinking water sources. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.

4.2  Water, Sanitation, and Hygiene

not available and the prices charged for water are exorbitant. Water used for drinking, hygiene, and other purposes must be free of toxins like arsenic, which can leak into wells when groundwater flows through fluvial deposits that contain arsenopyrites.11 Arsenic in the water has long been a problem in Bangladesh,12 where millions of residents remain at risk of ­arsenicosis, chronic arsenic poisoning from being exposed to contaminated water over a long period of time. The most visible symptoms are a change in skin color (hyperpigmentation) and the formation of hard skin patches (­keratosis). Arsenicosis can also cause skin cancer and cancers of the lung, kidney, and bladder as well as liver damage and peripheral vascular disease. Low-cost filter systems can remove arsenic from drinking water, but even a very low-cost filter is more expensive than many Bangladeshi families can afford. Because the filters produce toxic waste, they are at best only a temporary solution. Deeper wells that bypass the geologic formations that contain arsenic might solve the problem, but digging a deeper well is an expensive solution in low-­ income communities.13 Sanitation is the safe disposal of human excreta (feces). A household has access to

sanitation when there is a toilet in the home or a latrine near the home that can be used without a per-use payment (FIGURE 4–7).10 One of the most basic sanitation systems is a simple pit latrine, which is a hole in the ground covered by an outhouse or encircled by a privacy blind. An improved toilet facility provides greater comfort, privacy, cleanliness, safety, and protection from dangers at night and from snakes and pests. For example, a ventilation-­ improved pit (VIP) latrine vents fumes away from the outhouse and keeps flies out of it. Pour-flush systems require some water for washing away the waste. Septic tanks and sewer connections are more advanced sanitation technologies that use water to remove waste from indoor toilets. Open defecation occurs when people defecate in a field, a street, or another place that is not a toilet facility. Rural residents without access to sanitation systems may be able to go to an outdoor defecation site away from their living areas. Urban residents without access to a latrine often have no choice but to defecate at the side of a road or into a bag that is thrown outside, a waste disposal method that is sometimes called a “flying toilet.” A desire for privacy means that many people without an improved Improved

Unimproved • Open defecation (using a field, forest, bush, open body of water, beach, or other open space as a toilet)

71

• Pit latrine without a slab or platform

• Shared or public sanitation facilities

• Hanging latrine • Bucket (or bag) latrine • Flush or pour toilet that drains into a street, yard, open sewer, ditch, or drainage way

• Flush or pour toilet that diverts waste to a piped sewer system, a septic tank, or a pit latrine • Ventilated improved pit (VIP) latrine • Pit latrine with slab • Composting toilet

FIGURE 4–7  Examples of improved and unimproved sanitation facilities. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.

72

Chapter 4 Environmental Determinants of Health

sanitation facility, especially women, wait until dark to defecate, even though it is often dangerous for them to be out at night. A community is open defecation free (ODF) when all members are using designated toilet facilities and no one is defecating outside. Becoming an ODF community requires toilets to be present and used consistently by all community members. ­Community-led total ­sanitation (CLTS) programs are often implemented to encourage toilet use in places where residents are accustomed to open defecation and have not yet adopted new sanitation behaviors.14 The percentage of the world’s people with an improved water source increased from 76% in 1990 to 91% in 2015 (FIGURE 4–8).10 While nearly everyone in high-income countries has access to water, more than 1 in 10 people living in low- and middle-income countries—more

WASH-associated mortality per 100,000 people per year

60

50

40

30

20

10

U G SA er m an y Ira n Br az il C hi na In di N a ig er Et ia hi op ia

0

FIGURE 4–8  Mortality attributed to exposure to unsafe water, sanitation, and hygiene services per 100,000 people. Data from World health statistics 2016. Geneva: WHO; 2016.

than 650 million people—still did not have access to a reliable source of safe drinking water in 2015 (FIGURE 4–9). Access to an improved sanitation facility increased from 54% of the world’s people in 1990 to 68% in 2015 (FIGURE 4–10).10 However, in 2015 about 1 in 3 people worldwide—2.4 billion p ­ eople— still did not have access to an improved toilet (FIGURE  4–11). Even though the proportion of people worldwide who practice open defecation has decreased, about 950 million people still practiced open defecation in 2015 (FIGURE  4–12). Rates of water and sanitation access are often especially low in rural areas (FIGURE 4–13). In 2015, 96% of urban residents had an improved water source and 82% had an improved sanitation facility. In rural areas, the rates were 84% for water and only 51% for sanitation.10 People who do not have access to improved water and sanitation are at increased risk for infectious diseases that are spread through contact with fecal matter.15 In lower-income countries where few people have reliable access to water and sanitation, there is a substantial mortality rate associated with lack of access to these tools for health (­FIGURE  4–14).16 The presence of feces in or near homes significantly increases the risk of bacterial, viral, and protozoal diarrheal diseases and helminthic (worm) infections. Intestinal worm infections can be treated through the periodic distribution of de-worming medicines to school-age children and other at-risk population groups, but improved sanitation is a necessity for preventing new infections and reinfections. The best interventions for reducing the public health burden from diarrheal diseases and intestinal parasites are water, sanitation, and hygiene (WASH) programs that combine improved water and sanitation systems with health education to promote frequent handwashing and consistent use of toilets.17 Millennium Development Goal 7 aimed to reduce the proportion of people without access to water and sanitation by half between 1990 and 2015. The target for water

4.2  Water, Sanitation, and Hygiene

73

100 global average 2015

80

global average 1990

60

40

20

0 USA

Germany

Iran

Brazil 1990

China

India

Nigeria

Ethiopia

2015

FIGURE 4–9  Improvement in access to improved drinking water sources, 1990–2015. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.

Missing/Excluded Less than 60 60 to 80 80 to 95 95 to 99 99 and above

FIGURE 4–10  Proportion of the total population with access to an improved water source (2015). Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.

74

Chapter 4 Environmental Determinants of Health

100

80 global average 2015 60

global average 1990

40

20

0 USA

Germany

Iran

Brazil

China

1990

2015

India

Nigeria

Ethiopia

FIGURE 4–11  Improvement in access to improved sanitation facilities, 1990–2015. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/ World Health Organization; 2015.

Missing/Excluded Less then 50 50 to 75 75 to 90 90 to 99 99 and above

FIGURE 4–12  Proportion of the total population with access to an improved sanitation facility (2015). Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.

4.3  Energy and Air Quality 1990

2015

75%

44%

650 million

560 million

24% 22 million

25% 45 million

92% 44 million

29% 29 million

India

75

income per person in lower-income countries are associated with significantly greater levels of access to an improved drinking water source and sanitation (FIGURE  4–17).18 Both economic growth and access to water and sanitation are associated with improvements in population health status.19 WASH interventions are cost-effective means for reducing the preventable burden of waterand ­sanitation-related diseases in low- and ­middle-income countries.20

Nigeria

▸▸

Ethiopia

24% 1.3 billion

13% 946 million

World

FIGURE 4–13  Open defecation is still practiced by nearly 1 billion people worldwide. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.

was met, but the target for sanitation was not, despite good progress toward achieving it (FIGURE 4–15).10 SDG 6 has the even more ambitious goal of “ensuring available and sustainable management of water and sanitation for all.”4 A series of targets spell out how universal access to WASH can be achieved (FIGURE  4–16). There is a synergy between economic growth, WASH, and health. Economic development improves access to utilities, and increased access to utilities enables economic growth. Even small increases in

4.3  Energy and Air Quality

Energy is necessary for at least three important purposes: cooking food and boiling water for safe consumption, providing a source of heat when outdoor temperatures are low, and providing a source of light at night. The percentage of the world’s people with electricity in their homes increased from about 75% in 1990 to about 85% by 2015 (FIGURE 4–18).21 Nearly all of the 1.1 billion people without electricity at home live in lower-income countries. Having electricity does not mean that electricity is the only source of household energy. About 40% of people w ­ orldwide— about 2.9 billion people who live in lowand middle-income countries—use solid fuels like wood, charcoal, coal, dung, and

© Svetlana Eremina/Shutterstock

Rural water

er

Urban sanitation

ia op

ia

hi

U G

er

op hi Et

a

ig

di

N

In

na hi C

az

Ira

Br

er

m

U G

Urban water

er

0%

Et

0%

a

10%

ig

10%

di

20%

N

20%

In

30%

na

30%

il

40%

hi

40%

C

50%

az

50%

n

60%

Br

60%

Ira

70%

SA

70%

ia

80%

ia

80%

il

90%

n

90%

an y

100%

SA

100%

an y

Chapter 4 Environmental Determinants of Health

m

76

Rural sanitation

FIGURE 4–14  Rural areas often have less access to improved drinking water sources and sanitation facilities than urban areas. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015. Water

Sanitation

100%

100%

90%

90%

80%

80%

70%

70%

60%

60%

50% 40% 30%

MDG target met

50% 40% 30%

20%

20%

10%

10%

0%

MDG target not met

0% 1990 1995 2000 2005 2010 2015 2020 2025 2030

1990 1995 2000 2005 2010 2015 2020 2025 2030

FIGURE 4–15  The Millennium Development Goal (MDG) target for water was met, but progress for sanitation was not met. Data from Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF/WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015.

crop waste as their primary source of energy for cooking (FIGURE 4–19).21 Household air pollution, also called indoor air pollution, occurs when the air in or near

buildings is of poor quality. All fuels that are burned for energy release air pollutants, but biomass (fuel from organic materials like wood, vegetation, or animal waste) and

4.3  Energy and Air Quality

6.1

Achieve universal and equitable access to safe and affordable drinking water for all.

6.2

Achieve access to adequate and equitable sanitation and hygiene for all (including a handwashing facility with soap and water) and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations.

6.3

Improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally.

6.4

Substantially increase water-use efficiency across all sectors and ensure sustainable withdrawals and supply of freshwater to address water scarcity and substantially reduce the number of people suffering from water scarcity.

6.5

Implement integrated water resources management at all levels, including through transboundary cooperation as appropriate.

6.6

Protect and restore water-related ecosystems, including mountains, forests, wetlands, rivers, aquifers, and lakes.

6.a

Expand international cooperation and capacity-building support to developing countries in water- and sanitation-related activities and programs, including water harvesting, desalination, water efficiency, wastewater treatment, recycling, and reuse technologies.

6.b

Support and strengthen the participation of local communities in improving water and sanitation management.

FIGURE 4–16  Targets for Sustainable Development Goal 6, which focuses on water and sanitation. Data from United Nations. Transforming our world: The 2030 Agenda for Sustainable Development. New York: UN; 2015.

77

other solid fuels are particularly unhealthy because they are usually burned in open fires or in simple stoves that release most of the smoke from burning into the home or cooking shelter.22 The health risks associated with indoor air pollution levels are particularly high for women and young children who spend several hours a day near fires while cooking.23 Use of solid fuels for cooking and other energy needs can have adverse effects on respiratory health as well as other negative health outcomes.24 Children are at risk of burns from falling into open fires or knocking over pots of boiling water. Women and children often spend hours each week collecting sticks and brush to use as fuel, and they are susceptible to injuries related to carrying heavy loads over uneven terrain. As sources of biomass close to the home are used up, fuel-­gatherers must travel further distances to find fuel. There are also environmental consequences. Burning of solid fuels contributes to outdoor air pollution, and the demand for wood and charcoal contributes to deforestation. Having electricity in the home and being able to cook without solid fuels has numerous benefits, including cleaner indoor air, safer food storage because of access to refrigeration, and greater access to health and safety messages delivered through radios or televisions. However, electricity is not a p ­ ollution-free form of energy when the energy is generated by burning coal or oil. Power plants, the exhaust from motor vehicles, and the wastes produced by industrial processes, forest fires, and the disposal of solid waste can all create a ­ mbient air ­pollution, also called o ­ utdoor air pollution, which is the presence of harmful chemicals or other substances in the air at concentrations above the thresholds established for human safety. People in ­higher-income countries use more energy than people in lower-income countries, and they also generate more emissions per person

Chapter 4 Environmental Determinants of Health

Percentage of the population with access to an improved water source

78

100

IND

90

BRA GER USA IRAN

CHI

80 70

NIG

ETH

60 50 40 30 20 10 0 100

1000

10000

100000

Percentage of the population with access to an improved sanitation facility

GNI per capita (Atlas method, logarithmic scale)

100

IRAN

GER USA

90 BRA

80 CHI

70 60 50 40

IND

ETH

30

NIG

20 10 0 100

1000

10000

100000

GNI per capita (Atlas method, logarithmic scale)

FIGURE 4–17  Small increases in income per person in low-income countries are associated with significant increases in access to an improved drinking water source and an improved sanitation facility. (The dots represent the 100 most populous countries. Note the use of the logarithmic scale on the x-axis.) Data from World development indicators 2016 (Table 2.9). Washington DC: World Bank; 2016.

than less-industrialized lower-­income countries (FIGURE 4–20).25 Both indoor and outdoor air pollution are hazards to human health. The substances in polluted air include carbon monoxide (CO), nitrogen oxides (NOx), sulfur dioxide (SO2), ozone (O3), volatile organic compounds, and particulate matter. Particulate matter describes substances that are small enough to remain

suspended in the air for long periods of time and can travel deep into the lungs.26 Air pollutants can cause lung disease by triggering inflammation, damaging the cells that line the respiratory tract, and impairing immune response. They increase the risk of numerous respiratory diseases, including pneumonia, asthma, lung cancer, and other chronic respiratory diseases, and they exacerbate cardiovascular disorders.27

4.3  Energy and Air Quality

79

100%

80%

60%

40%

20%

0%

USA

Germany

Iran

Brazil

1990

China

2000

India

Nigeria Ethiopia

2010

FIGURE 4–18  Many homes in lower-income countries do not have electricity.

100 90 80 70 60 50 40 30 20 10 0

ia

op ia

Et

hi

a

ig er

In di

N

il

na hi

C

az

Ira

Br

er G

n

global average

U SA m an y

% without non-solid fuels

Data from Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017.

FIGURE 4–19  Most residents of low-income countries burn solid fuels to cook food rather than using clean fuels and technologies. Data from Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017.

In many low- and middle-income countries, a sizeable proportion of deaths are attributed to the combined effects of indoor and outdoor air pollution (FIGURE 4–21).16

SDG 7 is focused on “ensuring access to affordable, reliable, sustainable, and modern energy for all” (FIGURE 4–22).4 In lower-­income countries, progress toward this goal will be met by increasing the proportion of households with electricity, since indoor air pollution levels will be reduced when fewer people cook with solid fuels. There are also interventions that can reduce exposure to indoor air pollution among people without electricity.28 Using a cook stove with a flue that diverts pollutants out of the home improves indoor air quality. When it is not possible to increase ventilation inside the home, moving the kitchen to the outside of the home reduces smoke inhalation (if the outside cooking area has a good ventilation system). Improved cooking devices such as those that use solar panels or other alternative energy sources generally create less smoke than biomass. It is also helpful to change behaviors to reduce the health risks associated with cooking, such as keeping children away

Chapter 4 Environmental Determinants of Health

18

6000 5000 4000 3000 global average

2000 1000

CO2 emissions per capita (metric tons)

7000

16 14 12 10 8 6

global average

4 2

op

ia

ia

hi

er

di a

ig

In

il

hi na

C

n

az Br

N

Et

G

Ira

U

an y

ia

ia

op

er

Et

hi

ig

di a

N

In

il az

hi na

C

n Ira

Br

an y

U

er m G

SA

0

0

SA

Energy use per person (kg oil equivalent)

8000

er m

80

FIGURE 4–20  People in higher-income countries use more energy and generate more carbon dioxide emissions than people in low-income countries. Data from The little green data book 2016. Washington DC: World Bank; 2016.

180

7.1

Ensure universal access to affordable, reliable, and modern energy services.

7.2

Increase substantially the share of renewable energy in the global energy mix.

7.3

Double the global rate of improvement in energy efficiency.

7.a

Enhance international cooperation to facilitate access to clean energy research and technology, including renewable energy, energy efficiency, and advanced and cleaner fossil-fuel technology, and promote investment in energy infrastructure and clean energy technology.

7.b

Expand infrastructure and upgrade technology for supplying modern and sustainable energy services for all in developing countries, in particular, least developed countries, small island developing states, and landlocked developing countries.

Air pollution-related mortality per 100,000 people per year

160 140 120 100 80 60 40 20

G

er

U SA m an y Ira n Br az il C hi na In di N a ig er Et ia hi op ia

0

FIGURE 4–21  Mortality attributed to household and ambient air pollution per 100,000 people. Data from World health statistics 2016. Geneva: WHO; 2016.

from smoke and using pot lids to conserve heat. In higher-income countries, progress toward achieving SDG 7 will require generating a higher proportion of electricity from renewable sources that release fewer emissions into the air. Renewable energy is energy derived from a source like wind or solar power that is not depleted when it is used. Wind,

FIGURE 4–22  Targets for Sustainable Development Goal 7, which focuses on energy. Data from United Nations. Transforming our world: The 2030 agenda for sustainable development. New York: UN; 2015.

4.4  Occupational and Industrial Health

81

SDG 7 can only be met if the proportion of energy generated from renewable sources in those countries increases significantly.

Lignite coal Coal Oil Natural gas Solar photovoltaic

▸▸

Biomass Fossil fuels Renewable fuels

Hydroelectric Wind

Tons of CO2 emissions per GWh

FIGURE 4–23  Renewable sources emit fewer greenhouse gases (CO2 emissions per GWh) than nonrenewable energy sources. Data from Comparison of lifecycle greenhouse gas emissions of various electricity generation sources. London: World Nuclear Association (WNA); 2011. 100

% share of renewable energy in total final energy consumption

90 80 70 60 50 40 30 global average

20 10

hi

op

ia

ia

a

er

di

ig

In

il

na hi

C

n

az

Ira

an y

Br

N

Et

G

er

m

U

SA

0

FIGURE 4–24  Countries with high rates of electrification generally have small shares of energy consumption from renewable energy sources (including biofuels, hydro, wind, solar, geothermal, and other renewable sources). Data from Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017.

solar, ocean, geothermal, and other renewable sources of energy produce less environmental damage than combustible fossil fuel sources like oil and coal (­FIGURE  4–23).29 Countries with high rates of electrification generally have small shares of energy consumption from renewable energy sources (FIGURE 4–24),21 and

4.4  Occupational and Industrial Health

The field of occupational health, also called occupational safety and health and workplace health and safety, focuses on primary prevention of injuries and other work-related health problems. Occupational health was one of the first public health specialty fields.30 In 1713, Bernardino Ramazzini published Diseases of Workers, a book that detailed the environmental hazards encountered in 52 occupations, listing poisoning, respiratory diseases, problems related to prolonged postures and repetitive tasks, and psychological stress as some of many on-the-job threats to health. In 1753, James Lind published the results of an experiment that supported the hypothesis that sailors could prevent scurvy if they carried citrus fruit with them on long journeys.31 (After this discovery, sailors were sometimes called “limeys” for the citrus fruit carried on ships.) In 1775, Percivall Pott identified chimney soot as the cause of elevated rates of scrotal cancer in chimney sweeps, which was the result of constant exposure to coal tar due to sweeps rarely bathing or changing their trousers.32 New occupational risks continue to be identified today. Many workers are exposed to a mix of biological, chemical, physical, mechanical, and psychosocial challenges at work.33 Some occupations carry specific risks.34 Workers exposed to loud noises are at risk of permanently impaired hearing. Office and factory workers have an increased risk of repetitive strain injuries, such as carpal tunnel syndrome, that can develop after repeatedly performing the same tasks. Some workers who have longterm exposure to industrial chemicals are at increased risk of developing certain types of cancers. Those who work in the manufacturing industry may be at risk of crush wounds

82

Chapter 4 Environmental Determinants of Health

from moving parts. Medical workers are at risk of contracting infectious diseases from needle sticks and contact with body fluids. All workers may be subject to stress that can impair mental health.35 Specialists in industrial hygiene (also called occupational hygiene) assess and mitigate workplace hazards,36 such as issuing ear protection to workers in factories with high noise levels, making sure that people who spend their days in front of a computer have ergonomically designed chairs and are taking steps to minimize repetitive motion injuries, providing education about proper use of heavy machinery and hazardous materials, equipping healthcare workers with personal protective equipment, and providing wellness coaching. Each year, at least 1.1 million people die from on-the-job injuries and job-related diseases, including about 490,000 people who die from lung cancer, bladder cancer, and other cancers attributed to workplace exposure to harmful chemicals or radiation; 400,000 who die from work-related respiratory diseases, such as COPD, asthma, and pneumoconiosis, which is caused by inhalation of silica, asbestos, coal dust, and other substances; and 200,000 people who die from occupational injuries.37 Occupational risks are estimated to be responsible for 31% of years of life lived with low back pain, 27% of hearing loss, 15% of COPD, 8% of asthma, 8% of injuries, and 2% of leukemia cases worldwide.37 Every year there are more than 300 million occupational accidents that are severe enough to keep the injured person away from work for at least 4 days.38 Most occupational injuries, diseases, and deaths could be prevented if worksite managers and government officials enforced compliance with safety regulations.39 Toxicology is the study of the harmful effects that chemicals and other environmental materials can have on living things. Chemicals and other substances produced, handled, stored, transported, or disposed of at work and chemicals released from work activities can pose both acute (immediate) and long-term

© hedgehog94/Shutterstock

health risks to people exposed to them.40 Hazardous exposures in the workplace may include radiation, chemical pollutants, and toxic substances like polychlorinated biphenyls (PCBs), dioxins, asbestos, lead, mercury, cadmium, organic solvents, and pesticides. Many of these are released into the environment through industrial activities (FIGURE  4–25).41 Toxicologists study the effect of exposure frequency (how often a person is exposed), duration (the length of exposure at a given time), and dose (the amount of hazardous substance contacted) on health. They also assess the various exposure routes (like inhalation, ingestion, and absorption through the skin) and pathways (through air, water, food, soil, or other mechanisms) related to hazardous exposures. ­Carcinogens (substances that can cause genetic mutations that lead to cancer), ­teratogens (substances that can cause birth defects), and other hazards can be regulated or banned. Hazardous substances cause more than 500,000 deaths worldwide each year, including about 180,000 deaths attributable to asbestos, 120,000 attributable to diesel engine exhaust, 85,000 attributable to silica exposure, and several thousand deaths due to poisonings.37 Although these hazardous substances are used and produced in industrial settings in countries across the income spectrum, workers in lower-income countries have greater risks from occupational exposure. Many highly toxic agents that are heavily

4.4  Occupational and Industrial Health

83

Substance

Uses

Arsenic

Used to make “pressure-treated” lumber, as a pesticide for cotton plants, and in copper and lead smelting

Lead

Used in the production of batteries, ammunition, metal products (solder and pipes), and devices to shield X-rays; released from the burning of fossil fuels and during mining and manufacturing; used in some gasoline, paints, caulks, and ceramic products

Mercury

Used in thermometers, dental fillings, batteries, and some antiseptic creams and ointments

Vinyl chloride

Used to make polyvinyl chloride (PVC), plastic products like pipes, wire and cable coatings, and packaging materials

Polychlorinated biphenyls (PCBs)

Used as coolants and lubricants in transformers, capacitors, and other electrical equipment

Benzene

Used to make other chemicals that form plastics, resins, nylon and synthetic fibers, rubbers, lubricants, dyes, detergents, drugs, and pesticides

Cadmium

Extracted during the production of metals like zinc, lead, and copper for use in batteries, pigments, metal coatings, and plastics

Polycyclic aromatic hydrocarbons (PAHs)

A group of more than 100 different chemicals that are formed during incomplete burning of coal, oil, gas, garbage, tobacco, charbroiled meat, and other organic substances; also found in coal tar, crude oil, creosote, roofing tar, some medicines and dyes, plastics, and pesticides

FIGURE 4–25  Harmful substances commonly found at worksites (ATSDR 2015 Substance Priority List). Data from 2015 ATSDR Substance Priority List. Atlanta GA: U.S. Agency for Toxic Substances and Disease Registry (ATSDR); 2015.

regulated or banned in high-­income countries are still used in lower-income countries, and most workers in low-income countries where occupational regulations are rarely enforced do not have access to protective gear and safety training.42 Furthermore, in some places where paid jobs are scarce, work that requires repeated exposure to dangerous chemicals may be seen as the only alternative to unemployment. The industries producing the most pollution-related health problems worldwide include used lead acid battery recycling, mining and ore processing, lead smelting, tannery operating, artisanal small-scale gold mining,

industrial and municipal dumping, chemical and product manufacturing, and the dye industry.42 Ecotoxicology examines the impact of toxic exposures on populations, communities, and ecosystems. When industrial accidents occur, they often affect people who do not work at the site of an incident. The pollutants, toxins, and other substances released into air or water as a result of an accident can affect the local community and may spread to a larger area. The radioactivity released during the meltdown of the nuclear reactor at Chernobyl in Ukraine (then part of the USSR) in

84

Chapter 4 Environmental Determinants of Health

April 1986 spread a radioactive cloud across most of Europe. One health-related outcome of the meltdown was an increase in the incidence of thyroid cancer among children in the most contaminated regions.43 An accident at a chemical plant in Bhopal, India, in December 1984 released liquid and vapor methyl isocyanate. Several thousand people died when they were exposed to the fumes, some in their beds and others in the street after they staggered out of their homes to try to escape from the chemical. Hundreds of thousands of people sustained lung injuries.44 Routine industrial practices may also put entire communities at risk, especially in lower-income countries with few regulations to prevent environmental contamination.42 Chemical hazards in the home and community and at worksites can be especially dangerous for children who are still developing and growing. The risk of exposure to hazardous materials and other dangerous conditions is especially high for children who are sent to work at an early age. Some types of work, such as when rural children work alongside their parents on the family farm, can be a positive experience. But some children develop lasting physical and psychological scars from long hours doing domestic labor, agricultural work, or factory work. The International Labor Organization (ILO) makes a distinction between children participating in economic activity— working (whether for pay or not) for a few hours or full time doing activities other than household chores or schooling—and children who are involved in child labor.45 It is permissible for children aged 12 years and older to spend a few hours a week doing light work that is not hazardous. It is a child labor violation when a child has an excessive workload, unsafe work conditions, or extreme work intensity. Any of these conditions may harm a child’s physical health, mental health, or moral development. At worst, a child may be sold by his or her family into bonded labor, forced into sex work, or forced into armed conflict. In 2000, about 16% of all children between 5 and 17 years old were

engaged in child labor, about 245,000 children total. By 2012, the rate had dropped to about 10.6% of children, but there were still about 170,000 children engaged in child labor. That number included about 8.5% of children aged 5–11 years, 13.1% of children aged 12–14 years, and 13.0% of children aged 15–17 years.46 The proportion of children between 5 and 17 years old who were engaged in hazardous work dropped by half between 2000 and 2012, from 11% to 5.4%, but in 2012 about 85,000 children were still doing hazardous work.46 Two of the SDGs have targets that focus on occupational health, aiming to end child labor (SDG 8.7), to “promote safe and secure working environments for all workers” (SDG 8.8), and to “build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation” (SDG 9) with “increased resource-use efficiency and greater adoption of clean and environmentally sound technologies and industrial processes” (SDG 9.4).4 Many countries from all income levels have passed occupational and environmental health and safety laws,47 but meeting the SDG targets will require more attention on occupational health and safety, including protecting children from harmful labor, preventing workplace injuries and work-related diseases and disabilities, and safeguarding the health and safety of communities located near industrial sites.

▸▸

4.5 Urbanization

Urbanicity is the degree to which a particular location is urban, and it is a function of total population size, population density, population diversity, and access to city services like retail facilities and public transportation (FIGURE 4–26).48 Urbanicity is the opposite of rurality, the degree to which a particular location is rural. In 1950, about 30% of the world’s people lived in urban areas. That percentage increased to more than 50% by 2010 and is projected to further rise to more than 65% by 2050 (FIGURE 4–27).49 Most higher-­income

4.5 Urbanization

85

Missing/Excluded Less then 30 30 to 50 50 to 75 75 to 85 85 and above

FIGURE 4–26  Proportion of people living in urban areas (2015). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.

10 9 8

Billions

7 6 5 4 3 2 1 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 © Stephane Bidouze/Shutterstock Rural population

Urban population

FIGURE 4–27  The global urban population will continue to grow. Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.

countries have highly urban populations, while most lower-income countries continue to have mostly rural populations (­FIGURE 4–28). However, in nearly every country across the income spectrum, the proportion of the population

that lives in cities is increasing and is expected to continue to rise (FIGURE  4–29).49 SDG 11 has an aim of “making cities and human settlements inclusive, safe, resilient, and sustainable” through targets related to housing (SDG  11.1), transportation (SDG 11.2), air quality and waste management (SDG 11.6), and open public spaces (SDG 11.7).4 Because the majority of the world’s p ­ eople live in cities, urban health is a core component of global public health.50

86

Chapter 4 Environmental Determinants of Health

USA

Germany

Iran

Brazil Rural

China

India

Nigeria

Ethiopia

Urban

FIGURE 4–28  Percentage of each country living in an urban area (2015). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014. 100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% USA

Germany

Iran 1950

Brazil 1975

China 2000

2025

India

Nigeria

Ethiopia

2050

FIGURE 4–29  The proportion of the population living in an urban area is increasing in nearly every country and is projected to continue to increase. Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.

Urbanization is a shift toward more people living in cities and fewer people living in rural areas.51 Each day, thousands of people move from rural areas to cities in search

of better jobs, higher incomes, more social opportunities, and greater conveniences. Urbanization is occurring in nearly every part of the world, but this transition is happening

4.5 Urbanization

87

5

4

3

% change (2015–2020)

2

1

0 USA

Germany

Iran

Brazil

China

India

Nigeria

Ethiopia

-1

-2

-3 Rural

Urban

FIGURE 4–30  Urban areas are growing faster than rural areas (2015–2020). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.

most dramatically in low- and middle-income countries (­F IGURE  4–30).49 In upper-middle-­ income countries, birth rates are relatively low and rapid rates of rural-to-urban migration are causing rural populations to shrink as cities grow. In l­ ower-income countries, the birth rates remain high, but rural-to-urban migration is causing the urban population to grow much faster than the rural population. This process of urbanization affects both urban and rural residents. Rural women, for example, may bear a particularly heavy

burden when their husbands move to cities to find wage employment, leaving the women with the responsibility of completing all household chores. Parents who move to a city may have to leave their children in the care of rural-­dwelling grandparents, which puts a strain on three generations. On average, urban residents have greater access than rural residents to water and sanitation, to a relatively reliable public transportation system, and to healthcare providers and health technologies. Electricity in cities

88

Chapter 4 Environmental Determinants of Health

reduces cooking time and makes it easier to store food safely. Communications systems broadcast news and entertainment shows as well as emergency warnings and health messages. Urban women have more opportunities to pursue additional education and find employment outside the home. Pregnancy in cities is safer because of greater access to antenatal care and assistance by medical professionals during delivery. However, the benefits of urbanicity are not available to all urban residents ­(FIGURE 4–31). Many people who move to cities end up living in unplanned settlements (sometimes called shantytowns, slums, or squatter camps) where the quality of life is generally worse than rural life.52 In low- and middle-income countries, clusters of temporary structures are often quickly erected at the outskirts of large cities to accommodate rural-to-urban migrants. The structures are often built with cardboard or scraps of metal, wood, or other found objects, and they may provide little comfort or privacy and only minimal protection from the sun, rain, wind, and other elements. These dwellings may eventually be replaced with shacks built from blocks or bricks with a tin or asbestos roof, or they may be replaced with sturdier houses constructed from cement. Many years may pass before these growing communities have access to critical utilities. Residents might not have access to toilets. Informal dwellings are often built in floodplains or on other vulnerable lands, and lack of drainage systems means that floods carry feces and other waste into homes. Trash and human waste might collect near the home and attract rodents and insects, increasing the risk of infectious diseases. Cooking indoors with solid fuels generates high levels of air pollution. Unplanned communities in urbanizing cities are often located in undesirable locations near noisy and polluted highways or industrial centers that exacerbate asthma and cardiovascular conditions. Urban workers may face new occupational hazards, and they might not have access to affordable emergency healthcare services.

Violence related to crowding and road-­traffic accidents (often of the motor vehicle versus pedestrian variety) might be common. It might be difficult to grow or purchase nutritious foods, and there may be little time or space for exercising. There are numerous public health responsibilities that are common to all large population centers globally, including maintaining a safe built environment, managing water and sanitation services, disposing of waste, minimizing pollutants, and addressing other infrastructure issues.53 The similarities are especially prominent among megacities. A ­megacity is a metropolitan area with 10 million or more inhabitants. The number of megacities increased from 10 in 1990 to 29 in 2015, and that count is expected to rise to 41 by 2030 (­FIGURE 4–32).49 As the world urbanizes, the ability to achieve public health goals will depend on cities being safe, resilient, and sustainable. This will require cities in low- and middle-income countries to address the health-related challenges associated with poverty, socioeconomic inequalities, and environmental hazards.54

▸▸

4.6 Sustainability

A sustainable system is one that is able to be maintained at a particular level. When the term is used as part of the SDGs, the word sustainability emphasizes the need to provide for current human needs without compromising the ability of future generations to meet their needs.55 Sustainability has been described as a combination of “3 Es”: ethics (or equity), environment, and economics.56 These concepts have been expanded in the SDGs to include “5 Ps”: people, planet, prosperity (or profit), peace, and partnership.4 SDG 12 has an aim of “ensuring sustainable consumption and production patterns” through targets related to management of natural resources (SDG 12.2), reduction of food waste (SDG 12.3), management of hazardous waste (SDG 12.4), and improvements

■■

Nutrition

■■

Facilities may be far from home and may provide only basic care

May have limited ability to purchase food Can usually grow, gather, or hunt for food

Indoor air pollution from burning biomass

Solid fuels, which may be able to be collected locally

Potential exposure to agrochemicals like fertilizer and pesticides

Solid waste is burned or buried

May have inadequate sanitation facilities Open defecation in a field away from the house may be common

May have minimal access to improved water sources Risk of microbial contamination

■■

■■

■■

■■

■■

■■

■■

■■

■■

■■

■■

■■

■■

Facilities may be crowded and understaffed

May have limited access to affordable, healthy foods May not have space for a garden

Both indoor and outdoor air pollution Noise pollution

Solid fuels, which may be expensive

Potential exposure to industrial waste

No collection of solid waste Trash heaps create a habitat for insect and rodent vectors

May have inadequate sanitation facilities Open defecation in the street may be common

May have minimal access to affordable clean water Risk of microbial exposure and industrial and agricultural chemical contamination

Unplanned Urban

FIGURE 4–31  Comparison of health risks associated with living in rural, unplanned urban, and planned urban areas.

Health facilities

■■

Air quality

■■

■■

■■

■■

■■

■■

■■

■■

Rural

Fuel

Chemical hazards

Trash disposal

Sanitation

Water

Sector

■■

■■

■■

■■

■■

■■

■■

■■

■■

Basic, emergency, and specialty healthcare (including mental health and rehabilitation) facilities are available

Adequate access to healthy and safe dietary choices

Some outdoor air pollution Some indoor air pollution from building materials

Electricity

Little exposure to industrial or agricultural hazards

Solid waste is collected and removed

Sewage system

Reliable access to safe, clean drinking water

Planned Urban

4.6 Sustainability 89

90

Chapter 4 Environmental Determinants of Health

Rank Metropolitan area

Country

Population (2015)

1

Tokyo

Japan

38.0 million

2

Delhi

India

25.7 million

3

Shanghal

China

23.7 million

4

São Paul

Brazil

21.1 million

5

Mumbai

India

21.0 million

6

Mexico city

Mexico

21.0 million

7

Beijing

China

20.4 million

8

Osaka

Japan

20.2 million

9

Cairo

Egypt

18.8 million

10

New York

USA

18.6 million

11

Dhaka

Bangladesh

17.6 million

12

Karachi

Pakistan

16.6 million

13

Buenos Aires

Argentina

15.2 million

14

Kolkata

India

14.9 million

15

Istanbul

Turkey

14.2 million

16

Chongqing

China

13.3 million

17

Lagos

Nigeria

13.1 million

18

Manila

Philippines

13.0 million

19

Rio de Janeiro

Brazil

19.9 million

20

Guangzhou

China

12.5 million

21

Los Angeles

USA

12.3 million

22

Moscow

Russia

12.2 million

23

Kinshasa

DR Congo

11.6 million

24

Tianjin

China

11.2 million

25

Paris

France

10.8 million

26

Shenzhen

China

10.8 million

27

Jakarta

Indonesia

10.3 million

28

London

UK

10.3 million

29

Bangalore

India

10.1 million

FIGURE 4–32  The world’s megacities (urban areas of 10 million or more inhabitants). Data from United Nations Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014.

in recycling and reuse (SDG 12.5).4 The concept of sustainability is also integrated into all of the other SDGs. The SDGs are intended to reduce poverty and disease for today’s people while ensuring that future generations inherit a healthy planet that allows them to enjoy long, healthy lives.57

Courtesy of United Nations Information Centre

Sustainability has grown in prominence as a global priority in recent decades because of the rapid increase in the size of the human population. The dangers of overpopulation can be illustrated by comparing Earth to an island. Picture a small island in the middle of an ocean. It is arable (that is, it can grow food) and it has a variety of plant and animal species. At first, ten people settle on the island. They build homes, develop a system for collecting freshwater (because ocean water is too salty to drink or use for irrigation), and begin to farm the land. They also begin to have children, and eventually those children have children. Soon, the population has reached 100, and then it grows to 1000. The amount of land available for farming decreases as more homes are built, but the need for food is greater because there are more people to feed. Getting rid of waste products and finding energy sources are increasingly difficult. The limited amount of freshwater available is becoming a source of stress as the demand for water increases, but water quality is becoming poorer as waste pollutes water sources. Some plants and animals are threatened and at risk of extinction. Crime is increasing as resources become scarce. These challenges could be expected to become even worse as the population continues to grow.

4.6 Sustainability

8 7

Billions

6 5 4 3 2 1 0 0

200 400 600 800 1000 12001400 160018002000 Years

FIGURE 4–33  The “J-shaped curve” for world ­ opulation growth. p Data from United Nations Department of Economic and Social Affairs. World population to 2300. New York: UN; 2004.

Overpopulation occurs when a population becomes so large that the amount of food and other environmental resources available are insufficient to support all members of the population. The size of the Earth’s human population remained relatively steady for millennia, but recent growth has been exponential. A plot of the world’s population shows a “J-shaped” growth pattern (FIGURE 4–33).58 The doubling time, the number of years it takes for the world’s population to double in number, is getting shorter. It took only 40 years—from 1950 until 1990—for the number of humans to double from 2.5 billion to 5 billion. The current world population is more than 7 ­billion, and demographers project that the global population may rise to 11 billion by 2100.59 The population might stabilize after that time, but it might also grow or shrink depending on numerous socioeconomic and environmental factors that will unfold over the coming decades. In 1798, Thomas Malthus hypothesized that overpopulation leads to catastrophes like famines, epidemics, and wars.60 In the 21st century, this idea is expressed in terms of concerns about the unequal distribution of food and natural resources, the risks associated with the increased pollution and congestion that will occur with continued population growth, and the likelihood of increased crime and conflict as resources in some regions of the world become scarce. For example, many countries are already

91

facing water scarcity crises, especially small island nations and desert countries where internal freshwater resources are extremely limited, and water wars are seen as a possibility in the coming decades as more people compete for control over the world’s finite supply of the freshwater that is essential for survival.61 Carrying capacity is the maximum human population the Earth can sustain. There is no easy way to calculate the carrying capacity, because it depends on the standard of living and cultural factors in addition to population density (measured as land area per person or as arable land area per person), climate, and the land and natural resources that are available. However, carrying capacity can be approximated based on estimations of the per capita area of land needed to meet a population’s consumption patterns. The ­ecological footprint is a measure of how much burden human consumption places on the biosphere. People in high-income countries have large ecological footprints and use many more resources per person than people in low-­income countries (FIGURE 4–34).62 Earth likely could not support the current world population if everyone had the current ecological footprint of high-income countries, but most people in low- and middle-­income countries aspire to the higher standards of living that come with larger ecological footprints. As countries’ economies grow, their residents tend to use more resources per person. Sustainable development promotes economic growth while simultaneously protecting the environment from the adverse effects that typically accompany industrialization.63 Sustainable global health programs aim to generate long-term health benefits that endure even after specific projects end. A program that depletes natural resources and promotes overconsumption is not sustainable.64 A program that is fully dependent on outside donors and does not involve recipients in planning, ­decision-making, and evaluation is not sustainable. Ideally, global health programs should foster capacity building and encourage the

92

Chapter 4 Environmental Determinants of Health

10

Ecological footprint (global hectares per capita)

9 8 7 6 5 4 3

include habitat loss and degradation, species overexploitation, pollution, invasive plant and animal species that crowd out native species in a location, the dissemination of pathogens in new areas due to human transportation systems, and climate change.68 Humans can promote planetary health by preserving and restoring natural resources, producing energy and goods more efficiently and less wastefully, and consuming resources more wisely.68

2 1

G USA er m an y Ira n Br az C il hi na In d N ia ig er Et ia hi op ia

0

FIGURE 4–34  Ecological footprints are higher in high-income countries than in lower-income ­countries (2012). Data from National footprint accounts 2016. Oakland CA: Global Footprint Network; 2016.

self-sufficiency of participating communities, such as by facilitating the integration of successful externally funded healthcare programs into the routine services offered by internally funded national healthcare systems.65 Sustainability applies to human behavior and also to larger ecological processes. ­Biodiversity is the presence of a wide variety of plant and animal species within a particular environment. An ecosystem is sustainable when it can maintain its biodiversity and level of productivity indefinitely. The One Health concept emphasizes the interconnectedness of human health, animal health, and ecological health.66 Humans are dependent on plants and animals for food, and human lives are threatened when domestic animals, wildlife, agricultural crops, and other biological entities are harmed by environmental degradation and disease. The emerging field of planetary health emphasizes the dependence of human health on the Earth, and seeks to understand the damage that human actions can impose on ecosystem health.67 Threats to the health of the planet

▸▸

4.7  Climate Change and Health

Three of the SDGs address macro-level concerns about global environmental health. SDG 13 aims to “take urgent action to combat ­climate change and its impacts,” with a focus on strengthening resilience to respond to “climate-related hazards and natural disasters” (SDG 13.1). SDG 14 aims to “conserve and sustainably use the oceans, seas, and marine resources.” SDG 15 aims to “protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss.”4 At the local level, it can be easy to observe the health effects of human actions that alter the environment. Infrastructural development like building permanent structures, converting forests to farms, terracing slopes for agricultural use, paving streets, installing electrical lines and sewers, building dams, extracting fossil fuels to make oil and other petroleum products, and a host of other activities has increased the quality of life for billions of people. But any intentional change to the local environment may have some unintended side effects that adversely affect human health.69 For example, building a dam may prevent flooding and improve agricultural productivity, but having a larger body of water nearby may increase the risk of some insect-transmitted infections and intestinal worm infestations.70

4.7  Climate Change and Health

The immediate effects of most human activities are local, but the distinction between local and global environmental change is getting blurrier. In a globalized world, the choices any person makes about where to live, work, and travel and what to purchase can have an impact on people who live in distant lands. The air pollution created by millions of commuters driving to work each day in one city does not just damage their airspace, but that of their neighbors. When electronic waste (e-waste) and other types of garbage are discarded by people in high-income countries, the potentially toxic materials may be shipped to dumps in lower-income countries.71 Deforestation and habitat destruction, soil erosion and salinization, water management problems, overhunting and overfishing, invasive species (which may crowd out local flora and fauna), human population growth, and increasing use of resources per capita all can have local and global impacts.72 Climate change is a long-term shift in weather patterns and average temperatures. One component of climate change is global warming, a gradual increase in the temperature of the Earth’s atmosphere. The cumulative effect of the intensified use of natural resources across the planet appears

93

to be contributing to global climate change. The Intergovernmental Panel on ­Climate Change (IPCC), a scientific board that reviews and synthesizes scientific data about climate and weather under the auspices of the United Nations, has expressed certainty that global climate changes are occurring and will continue to occur for centuries to come.73 The impacts of global climate change include land degradation, water and air quality issues, biodiversity loss, and temperature and precipitation extremes. The IPCC has also concluded that the observed changes are very likely due to human activity.74 While cycles of climate change have occurred throughout history, there is growing concern about the pace of climate variability.75 The IPCC predicts that climate change will mean more frequent hot days and nights, fewer cold days and nights, an increasing frequency of heat waves, an increase in the frequency of heavy precipitation events in some areas and an increase in droughts in others, an increase in tropical cyclone (hurricane) activity, and an increase in the incidence of extremely high sea levels.76 Many of these expected climate changes could have significant adverse impacts on human health (FIGURE  4–35).77 Extreme heat increases the rate of cardiovascular disease

Climate Change

Health Impact

Hot days become hotter and more frequent

Increased rate of heat-related mortality from cardiovascular, respiratory, and kidney diseases exacerbated by heat

Precipitation events become more frequent and more intense, with more extreme floods in some places and more extreme droughts in others

Increased risks of undernutrition and of waterborne and vectorborne (insect-transmitted) infectious diseases

High sea levels become more extreme

Increased risk of drowning

FIGURE 4–35  Examples of observed climate change trends and their likely impacts on human health. Data from Smith KR, Woodward A, Campbell-Lendrum D, et al. Human health: Impacts, adaptation, and co-benefits. In Climate change 2014: Impacts, adaptation, and vulnerability. Contribution of Working Group II to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2014.

94

Chapter 4 Environmental Determinants of Health

CDC/ Venecia Ramírez, Dominican Republic

mortality.78 Extreme weather events decrease air quality by increasing particulates and pollen in the air, and poor air quality exacerbates illness and mortality from respiratory and cardiovascular diseases.79 Floods, droughts, heat waves, and other weather extremes might reduce agricultural productivity, and ocean acidification might reduce aquacultural productivity, leading to greater levels of food insecurity.80 Extreme weather events can also increase the risks of diarrheal diseases, insectborne infectious like malaria and dengue fever, and drowning and other types of injuries.81 The negative impacts of climate change are likely to be especially detrimental to the world’s lowest-income people, who often live in places with greater environmental vulnerability and fewer resources to respond to threats.82 A series of international agreements have sought to combat climate change. The United Nations Framework Convention on Climate Change (FCCC) is an international environmental treaty that seeks to reduce greenhouse gas emissions.83 A greenhouse gas (GHG) is a gas in the atmosphere that traps heat and causes surface temperatures to increase. The GHGs of greatest concern include carbon dioxide (CO2), methane (CH4), nitrous oxide (N2O), and fluorinated gases such as sulfur hexafluoride (SF6), hydrofluorocarbons, and perfluorocarbons. The FCCC was negotiated

in 1992 at the UN Conference on Environment and Development, colloquially called the Earth Summit, which was held in Rio de Janeiro, Brazil, and went into force in 1994. The 1997 Kyoto Protocol sought to toughen the FCCC commitments to reduce GHG emissions by the high-income signatory countries that generate the most emissions.84 The 2015 Paris Agreement is a legally binding set of additional commitments from signatories across the income spectrum to reduce global warming and promote development that does not further exacerbate environmental damage.85 Regardless of arguments about the precise causes of global warming, the alarming trends documented by the IPCC support the value of humans treading more lightly on the Earth. For example, alternative energy sources that harness solar, wind, or wave power may be able to produce energy that creates less pollution and less environmental damage than ­carbon-based fuels, hydroelectric power (which requires the building of massive dams and flooding of large swaths of land), and nuclear power (which remains dangerous because of the risk of a meltdown). The short- and long-term risks and benefits of projects that alter the environment locally or more widely should be carefully considered before projects are initiated, and the assessments should include health and environmental evaluations as well as economic ones.86 Strategic plans for public health initiatives should examine the links between human and environmental health in the targeted populations and then account for the possible impact of climate change on health risks.87 In a globalized world, everyone has a stake in creating and sustaining a healthy environment.88

▸▸

References

1. Prüss-Ustün A, Wolf J, Corvalán C, Bos R, Neira M. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva: WHO; 2016. 2. Don’t pollute my future! The impact of the environment on children’s health. Geneva: WHO; 2017.

References 3. Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on pollution and health. Lancet. 2017. doi:10.1016/S0140-6736(17)32345-0 4. United Nations. Transforming our world: The 2030 Agenda for Sustainable Development. New York: UN; 2015. 5. UN Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2 /Rev.1). New York: UN; 2016. 6. Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003. 7. Guidelines for drinking water quality: 4th edition incorporating the first addendum. Geneva: WHO; 2017. 8. Water for life: Community water security. New York: Hesperian Foundation and UNDP; 2005. 9. Maupin MA, Kenney JF, Hutson SS, Lovelace JK, Barber NL, Linsey KS. Estimated use of water in the United States in 2010. Reston VA: U.S. Geological Survey; 2014. 10. Progress on sanitation and drinking water: 2015 update and MDG assessment. New York: UNICEF /WHO Joint Monitoring Programme for Water Supply and Sanitation; 2015. 11. Nordstrom DK. Worldwide occurrences of arsenic in ground water. Science. 2002;296:2143–4. 12. Smith AH, Lingas EO, Rahman M. Contamination of drinking-water by arsenic in Bangladesh: A public health emergency. Bull World Health Organ. 2000;78:1093–103. 13. Ahmed M, Jakariya M, Quaiyum M, Mahmud SN. An implementation guide for the Arsenic Mitigation Program. Dhaka: BRAC; 2002. 14. Kar K, Chambers R. Handbook on community-led total sanitation. London: Plan UK; 2008. 15. Preventing diarrhoea through better water, sanitation and hygiene: Exposures and impacts in low- and middle-income countries. Geneva: WHO; 2014. 16. World health statistics 2016. Geneva: WHO; 2016. 17. Mara D, Lane J, Scott B, Trouba D. Sanitation and health. PLoS Med. 2010; 7:e1000363. 18. World development indicators 2016 (Table 2.9). Washington: World Bank; 2016. 19. Hutton G, Chase C. Water supply, sanitation, and hygiene (Chapter 9). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume  7). Washington DC: IBRD/World Bank; 2017. 20. Watkins D, Dabestani N, Nugent R, Levin C. Interventions to prevent injuries and reduce environ­ mental and occupational hazards: A review of economic evaluations from low- and middle-income countries (Chapter 10). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017.

95

21. Progress toward sustainable energy 2017: Global tracking framework report. Washington DC: World Bank/IEA; 2017. 22. WHO guidelines for indoor air quality: Household fuel combustion. Geneva: WHO; 2014. 23. Fullerton DG, Bruce N, Gordon SB. Indoor air pollution from biomass fuel smoke is a major health concern in the developing world. Trans R Soc Trop Med Hyg. 2008;102:843–51. 24. Burning opportunity: Clean household energy for health, sustainable development, and wellbeing of women and children. Geneva: WHO; 2016. 25. The little green data book 2016. Washington DC: World Bank; 2016. 26. Kampa M, Castanas E. Human health effects of air pollution. Environ Pollut. 2008;151:362–7. 27. Brunekreef B, Holgate ST. Air pollution and health. Lancet. 2002;360:1233–42. 28. Smith KR, Pillarisetti A. Household air pollution from solid cookfuels and health (Chapter 7). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017. 29. Comparison of lifecycle greenhouse gas emissions of various electricity generation sources. London: World Nuclear Association (WNA); 2011. 30. Abrams HK. A short history of occupational health. J Public Health Policy. 2001;22:34–80. 31. Hughes RE. James Lind and the cure of scurvy: An experimental approach. Med Hist. 1975;19:342–51. 32. Waldron HA. A brief history of scrotal cancer. Br J Ind Med. 1983;40:390–401. 33. Abdalla S, Apramian S, Cantley L, Cullen M. Occupation and risk for injuries (Chapter 6). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017. 34. Encyclopedia of occupational health & safety. Geneva: ILO; 2017. 35. Leka S, Jain A. Health impact of the psychosocial hazards of work: An overview. Geneva: WHO; 2010. 36. A 5 step guide for employers, workers and their representatives on conducting workplace risk assessments. Geneva: ILO; 2014. 37. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602. 38. Safety and health at work: A vision for sustainable prevention. Geneva: ILO; 2014. 39. The prevention of occupational diseases. 4th ed. Geneva: ILO; 1998. 40. Safety and health in the use of chemicals at work. Geneva: ILO; 2013.

96

Chapter 4 Environmental Determinants of Health

41. 2015 ATSDR Substance Priority List. Atlanta, GA: U.S. Agency for Toxic Substances and Disease Registry (ATSDR); 2015. 42. The world’s worst pollution problems 2016: The toxins beneath our feet. New York: Pure Earth; 2016. 43. Shibata Y, Yamashita S, Masyakin VB, Panasyuk GD, Nagataki S. 15 years after Chernobyl: New evidence of thyroid cancer. Lancet. 2001;358:1965–6. 44. Mehta PS, Mehta AS, Mehta SJ, Makhijani AB. Bhopal tragedy’s health effects: A review of methyl isocyanate toxicity. JAMA. 1990;265:2781–7. 45. International Programme on the Elimination of Child Labour (IPEC). Children in hazardous work: What we know, what we need to do. Geneva: ILO; 2011. 46. Making progress against child labour: Global estimates and trends 2000–2012. Geneva: ILO; 2013. 47. WHO Global Plan of Action on Workers’ Health (2008–2017): Baseline for implementation. Geneva: WHO; 2013. 48. Dahly DL, Adair LS. Quantifying the urban environment: A scale measure of urbanicity outperforms the urban-rural dichotomy. Soc Sci Med. 2007;64:1407–19. 49. UN Department of Economic and Social Affairs. World urbanization prospects: The 2014 revision. New York: UN; 2014. 50. Health as the pulse of the new urban agenda: United Nations conference on housing and sustainable urban development, Quito, October 2016. Geneva: WHO; 2016. 51. Vlahov D, Galea S. Urbanization, urbanicity, and health. J Urban Health. 2002;79(Suppl 4):S1–12. 52. Moore M, Gould P, Keary BS. Global urbanization and impact on health. Int J Hyg Environ Health. 2003;206:269–78. 53. Galea S, Vlahov D. Urban health: Evidence, challenges, and directions. Annu Rev Public Health. 2005;26:341–65. 54. McMichael AJ. The urban environment and health in a world of increasing globalization: Issues for developing countries. Bull World Health Organ. 2000;78:1117–26. 55. Our common future. Geneva: World Commission on Environment and Development (WCED); 1987. 56. Goodland R. The concept of environmental sustainability. Annu Rev Ecol Systematics. 1995;26:1–24. 57. Inheriting a sustainable world? Atlas on children’s health and the environment. Geneva: WHO; 2017. 58. UN Department of Economic and Social Affairs. World population to 2300. New York: UN; 2004. 59. Gerland P, Raftery AE, Ševčíková H, et al. World population stabilization unlikely this century. Science. 2014;346:234–7.

60. Nekola JC, Allen CD, Brown JH, et al. The Malthusian–Darwinian dynamic and the trajectory of civilization. Trends Ecol Evol. 2013;28:127–30. 61. Shiva A. Water wars: Privatization, pollution, and profit. Cambridge MA: South End Press; 2002. 62. National footprint accounts 2016. Oakland CA: Global Footprint Network; 2016. 63. Lélé SM. Sustainable development: A critical review. World Dev. 1991;19:607–21. 64. Barbier EB. The concept of sustainable economic development. Environ Conserv. 1987;14:101–10. 65. Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: Conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998;13:87–108. 66. Zinsstag J, Schelling E, Waltner-Toews D, Tanner M. From “one medicine” to “one health” and systematic approaches to health and well-being. Prev Vet Med. 2011;101:148–56. 67. Whitmee S, Haines A, Beyrer C, et al. Safeguarding human health in the Anthropocene epoch: Report of The Rockefeller Foundation–Lancet Commission on planetary health. Lancet. 2015;386:1973–2028. 68. Living planet report 2016: Risk and resilience in a new era. Geneva: WWW International; 2016. 69. McMichael AJ, Campbell-Lendrum DH, Corvalán CF, et al. Climate change and human health: Risks and responses. Geneva: WHO; 2003. 70. Morse SS. Factors in the emergence of infectious diseases. Emerg Infect Dis. 1995;1:7–15. 71. Heacock M, Kelly CB, Asante KA, Birnbaum LS, Bergman Å, Bruné MN. E-waste and harm to vulnerable populations. Environ Health Perspect. 2016;124:550–5. 72. Diamond J. Collapse: How societies choose to fail or succeed. New York: Viking; 2005. 73. Pachauri RK, Meyer LA, editors. Climate change 2014: Synthesis report. Contribution of Working Groups I, II and III to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2014. 74. Stocker TF, Qin D, Plattner GK, et al., editors. Climate change 2013: The physical science basis. Contribution of Working Group I to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2013. 75. TBD. Health risks and costs of climate variability and change (Chapter 8). Disease control priorities. 3rd ed. Injury prevention and environmental health (Volume 7). Washington DC: IBRD/World Bank; 2017.

References 76. Field CB, Barros VR, Mastrandrea MD, et al., editors. Climate change 2014: Impacts, adaptation, and vulnerability. Contribution of Working Group II to the 5th Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge UK: Cambridge University Press; 2014. 77. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change. Lancet. 2009;373:1693–733. 78. Luber G, McGeehin M. Climate change and extreme heat events. Am J Prev Med. 2008;35:429–35. 79. D’Amato G, Cecchi L, D’Amato M, Annesi-Maesano I. Climate change and respiratory diseases. Eur Respir Rev. 2014;23:161–9. 80. Watts N, Adger WN, Ayeb-Karlsson S, et al. The Lancet countdown: Tracking progress on health and climate change. Lancet. 2017;389:1151–64. 81. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva: WHO; 2014.

97

82. Watts N, Adger WN, Agnolucci P, et al. Health and climate change: Policy responses to protect public health. Lancet. 2015;386:1861–914. 83. United Nations Framework Convention on Climate Change. New York: UN; 1992. 84. Kyoto Protocol to the United Nations Framework Convention on Climate Change. New York: UN; 1998. 85. Adoption of the Paris Agreement. (FCCC /CP/2015/L.9/Rev.1). New York: UN; 2015. 86. WHO guidance to protect health from climate change through health adaptation planning. Geneva: WHO; 2014. 87. Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: The public health response. Am J Public Health. 2008;98:435–45. 88. McMichael AJ, Beaglehole R. The changing global context of public health. Lancet. 2000;356:495–9.

© Xinzheng. All Rights Reserved/Moment/Getty

CHAPTER 5

Health and Humans Rights Global health is founded on the principle that all people have the right to the highest attainable standard of health. By becoming signatories to the Universal Declaration of Human Rights, all of the world’s countries have agreed that there are many human rights that every person is entitled to, including the right to medical care. Governments have an obligation to ensure that everyone has access to water, health services, essential medicines, and other basic human needs. Members of low-income households, victims of natural disasters and complex humanitarian emergencies, people in prison, and people with disabilities often have difficulty accessing health services and other human rights. One of the roles of global health is to advocate for the human rights of those vulnerable populations.

▸▸

5.1  Health and Human Rights

The preamble to the Constitution of the World Health Organization (WHO), which has been affirmed by the nearly 200 countries that have membership in the United Nations (UN), lists nine principles that serve as the foundational values for the field of global health (FIGURE  5–1). The boldest claim is that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being” (principle 2).1 This statement calls for quality health services to be accessible and affordable so that everyone has access to at least basic medical and psychological care (principle 7), especially children and people who are members of vulnerable population groups (principles 2 and 6). The preamble also notes that health is linked with peace 98

(principle 3) and security (principles 4 and 5), that everyone is at risk of outbreaks of infectious disease (principle 5), and that both the public (principle 8) and governments (principle 9) must take active responsibility for public health. Two key terms in the preamble require careful definition: human rights and standard of health. Human rights are entitlements that are due to every person simply because that person is human. Human rights are considered to be universal, which means that they apply to every person of all ages in all circumstances. The Universal Declaration of Human Rights (UDHR), which was unanimously adopted by the member states of the United Nations in 1948, spells out more than two dozen civil, political, economic, social, and cultural human rights (FIGURE 5–2).2 Articles 3–21 define civil and political rights that protect the foundational freedoms of

5.1  Health and Human Rights

99

1

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

2

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition.

3

The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals and States.

4

The achievement of any State in the promotion and protection of health is of value to all.

5

Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.

6

Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development.

7

The extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health.

8

Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people.

9

Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.

FIGURE 5–1  Health principles articulated in the Preamble to the Constitution of the World Health Organization. Data from Constitution of the World Health Organization. New York: United Nations; 1946.

humans, such as the right to privacy and the right to freedom from torture. These rights are about protections rather than provisions, and they can be granted and upheld with limited financial costs to governments. Articles 22–28 outline economic, social, and cultural rights that, if realized, would contribute to human flourishing. These rights, such as the right to social security, the right to education, and the right to a standard of living adequate for health and well-being, obligate governments to provide certain services to their people.3 Because these rights carry real monetary costs, they are somewhat aspirational. However, countries

are called to make progress toward increasing the economic, social, and cultural rights of their populations. The UDHR does not state that people have a right to be healthy. No government can guarantee health for anyone. For many diseases and disorders, there are currently no effective preventive methods or curative treatments, so there is no way for any entity to alleviate the burden from those health issues. But the UDHR does state that all people have the right to medical care and the underlying tools for health, such as safe drinking water and adequate nutrition, no matter where they live.4

100

Chapter 5 Health and Humans Rights

Human Right Right to equal dignity and human rights for all humans

UDHR Articles 1, 2

Right to life, liberty, and security of person

3

Freedom from slavery and servitude

4

Freedom from torture and cruel, inhuman, or degrading treatment or punishment

5

Right to recognition as a person

6

Freedom from discrimination

7

Right to legal protection of human rights

8

Freedom from arbitrary arrest, detention, or exile

9

Right to a fair trial

10

Right to be presumed innocent until proven guilty

11

Right to privacy

12

Freedom of movement

13

Right to asylum

14

Right to a nationality

15

Right to marry and found a family

16

Right to own property

17

Freedom of thought, conscience, and religion

18

Freedom of opinion and expression

19

Freedom of peaceful assembly and association

20

Right to participate in government

21

Right to social security

22

Right to work

23 (continues)

5.2  Access to Basic Human Needs

Human Right

101

UDHR Articles

Right to rest and leisure

24

Right to a standard of living adequate for the health and well-being of the individual and his/her family, including food, clothing, housing, medical care, and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, or old age

25

Right to education

26

Right to participate in the cultural life of a community

27

FIGURE 5–2  Key articles in the Universal Declaration of Human Rights. Data from The universal declaration of human rights. New York: United Nations; 1948.

The term standard of health refers to targets that governments set for improving the health of the populations they govern. Achieving the “highest attainable standard of health” requires increasing access to healthcare services and to the tools for health. All governments can strive to increase access to preventive and therapeutic services, starting with a basic package of healthcare services (such as antenatal care, childhood vaccinations, treatment of common infectious diseases, and access to clean water) and then expanding the range of services that are available to the entire population.5 Health and human rights are intertwined. People who are denied their human rights are unable to advocate for their own health, and populations that are unhealthy are unable to advocate for their rights.6 By adopting the UDHR, all UN member countries have affirmed their agreement that human rights are universal.7 When people in one country are being denied their human rights, people in other countries have the obligation to call attention to those violations. The goals of the field of health and human rights include providing education about rights, exposing human rights violations, increasing accountability for governments and other organizations involved in health and human services, and improving access to health and related services.8

Before the concept of the “right to health” can be fully integrated into national health strategies and operationalized at the global level, four key questions will need to be answered9: (1) What are the services and goods guaranteed to every person under the human right to health? (2) What responsibilities do states have for the health of their own populations? (3) What duties do states owe to people beyond their borders in securing the right to health? (4) What kind of global governance for health is needed to ensure that all states live up to their mutual responsibilities? However, the shared commitment to ensuring that everyone has the basic tools for survival and health has already been recognized in numerous international agreements.

▸▸

5.2  Access to Basic Human Needs

The most fundamental human right is the right to life. Human survival is dependent on having enough food, water, and air to support physiological processes and having sufficient shelter and clothing to protect the body from external exposures. These basic human needs are incorporated into the Sustainable Development Goals (SDGs) in targets that seek to

102

Chapter 5 Health and Humans Rights

“ensure that all men and women, in particular the poor and vulnerable, have equal rights to economic resources, as well as to basic services” (SDG 1.4) and to “ensure access for all to adequate, safe, and affordable housing and basic services” (SDG 11.1).10 Additional aspects of meeting these basic human needs are included in targets specific to health and nutrition, education, water and sanitation, energy, housing, and other goals. Because drinking water is something that everyone requires on a daily basis just to survive, access to water is considered to be a human right.11 This does not mean that everyone has a right to an unlimited amount of free water, but it does mean that everyone has a right to an adequate quantity of clean water for consumption and hygiene at a reasonable cost.12 Increasing access to water requires investments in water system infrastructure, which usually means digging new groundwater wells and protecting surface water sources, installing miles of pipelines and pumps to transport water from sources to consumers, and sometimes also constructing facilities to store and treat water. These improvements can be expensive, and the costs of building and maintaining the water system must usually be recouped through taxes or user fees. Additionally, user fees help promote conservation, which is important in places where freshwater resources are limited. Thus, freshwater is considered to be both an essential human need and a consumer good.13 Low-income households may struggle to access the water they need. For example, massive protests occurred in 2000 in Cochabamba, Bolivia’s third largest city, after the government leased the city’s water rights to a U.S.-based corporation in order to improve services and satisfy a condition of a World Bank loan.14 To raise capital for modernizing the water system, the company significantly increased user fees. For many low-income households, the higher cost of water was a huge burden. There was no legal way to reduce the cost of the household’s water. Residents were banned from using other water

sources, such as personal wells and storage tanks, and they were even forbidden to collect rainwater without a paid permit.15 After several months of escalating protests, the water system was re-nationalized. Water privatization schemes in countries in Latin America, Asia, Africa, and other parts of the world are generating similar concerns about how to guarantee that the poorest residents can access safe drinking water.16 Problems with ensuring equitable and affordable water access are not limited to low- and middle-income countries (LMICs). In 2015 alone, tens of thousands of households in both Detroit and Philadelphia, two large cities in the United States, had their water supplies shut off,17 and the discovery of high levels of lead in the municipal water system in Flint, Michigan, triggered a state of emergency that forced tens of thousands of households to rely on bottled water for drinking, cooking, and hygiene.18 In many western U.S. states, where a growing human population and agricultural intensification have placed extreme demands on the watershed, the ownership of various supplies of water is determined based on so-called water rights that were sold many decades ago to cities, farmers, ranchers, and miners. It is illegal for people who do not own rights to the local watershed to use river water or collect rainwater.19 When large cities like Los Angeles and Las Vegas require additional water for their growing populations, they can buy water rights from distant sources. Then, large volumes of water from those source rivers are rerouted to the purchasing city. In some places, diversion of water or excessive use of water by upstream consumers has left downstream communities that have historically had adequate water supplies with an insufficient amount of water.20 It can be difficult for those downstream populations to make a legal case for their right to the missing water, especially if the water crosses a state or national border (such as the U.S.–Mexican border). These sorts of ethical challenges will only become more acute as more people move to dry climates.

5.3  Access to Health Services

© Asianet-Pakistan/Shutterstock

Growing concerns about water scarcity in many countries and regions require conservation of precious freshwater resources (including the reduction of water loss during transport), clarification of the laws that govern water markets and water use, and a commitment to ensure adequate water access to v­ ulnerable populations.

▸▸

5.3  Access to Health Services

The right to health care is one of many human rights recognized in the Universal Declaration of Human Rights. Article 25 states that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services.”1 Several key criteria are used to evaluate access to health care, including availability, accessibility, affordability, acceptability, and quality.21 Health services are available when there are an adequate number of medical facilities that are functioning, staffed, and stocked with the necessary supplies. They are accessible when they are geographically and physically accessible to everyone, regardless of residential location and physical ability. Health services are affordable when they are economically accessible and payment for services is commensurate with ability to pay. They are acceptable when clinical care providers are respectful of patients from all ethnicities, sexes, ages, and other population groups. This may

103

mean adapting to cultural expectations, such as ensuring that a female healthcare provider examines female patients in nonemergency situations if that is the cultural expectation of the patient. The quality of healthcare services is based on having well-maintained facilities that are stocked with appropriate supplies and staffed by appropriately skilled workers. These criteria set a minimum standard for access to health care. They do not specify what constitutes an acceptable level of access to health personnel, medical specialists, tests and procedures, medications, and health technology. Those details are expected to be defined by each country for its own people. The right to health does not mean the right for everyone to have access to every health resource on demand. The economic reality is that most health systems cannot provide organ transplants to everyone who needs one to stay alive, expensive high-tech cancer treatments for everyone whose life could be extended by them, or years of intensive rehabilitation for everyone whose quality of life would improve with long-term care. Countries must make difficult decisions about which routine preventive health services and screenings will be covered by the national health plan, what types of emergency care will be provided to everyone with life-threatening injuries, which medications will be part of the health system’s formulary, who will be eligible for particular surgical procedures, and countless other considerations. These selections should be made after evaluating the effectiveness and cost-effectiveness of various medications, devices, and procedures aimed at improving survival and quality of life.22 The right to health requires equitable access to covered services, so the services included in a national health plan must be in alignment with the resources available, such as the number of medical specialists and support staff available to implement covered procedures.23 The level of access to quality health services is a major social, economic, and political concern in countries across the income spectrum. The United States has sought for decades

Chapter 5 Health and Humans Rights

to figure out how to increase the proportion of the population with health insurance, contain rising healthcare costs, and regulate private health insurance plans.24 Brazil, India, and China are all committed to providing universal access to healthcare services, but they are struggling to fund their health systems, improve the quality of care, and ensure access in rural areas.25 Every country has to make decisions about what healthcare services should be provided and who should pay for those services, and these decisions have human rights implications. The SDGs aim to “substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries and small island developing states” (SDG 3.c).10 At present, there is a very uneven distribution of healthcare workers across the globe. The WHO estimates that about 4.45 doctors, nurses, and nurse-midwives per 1000 people is the minimum ratio required for sustainable development. Higher ratios allow for higher-­ quality services to be provided. At present, there are about 14 skilled health professionals per 1000 people in high-income countries, 6 per 1000 in upper-middle-income countries, 4 per 1000 in l­ ower-middle-income countries, and only 1.5 per 1000 in l­ ow-income countries (FIGURE 5–3).26 This means that the number of people each clinician has to care for is higher in low-income countries ­ igh-income countries. For example, than in h while there is about one physician, nurse, or nurse-midwife for every 75 residents of ­Germany, there is only one skilled health professional for every 3570 residents of Ethiopia (FIGURE 5–4).27 ­Lower-income countries also have insufficient numbers of mental healthcare providers (FIGURE  5–5)28 and an inadequate number of dentists (FIGURE  5–6).29 Lower-income countries also have too few surgeons,30 which means that the majority of residents in these areas do not have timely

14

Clinicians per 1000 people

104

12 10 8 6

minimum acceptable rate

4 2 0 High income

Upper middle income

Lower middle income

Low income

Other health workers Nurses & midwives Physicians

FIGURE 5–3  There are many more physicians, nurses and midwives, and other health workers per 1000 residents in high-income countries than in lowincome countries. Data from Health workforce requirements for universal health coverage and the Sustainable Development Goals. Geneva: WHO; 2016.

access to safe and affordable surgical services (FIGURE 5–7).31 One of the factors contributing to these inequalities in access to human resources for health is brain drain, the migration of healthcare professionals trained in LMICs to higher paying jobs in high-income countries.32 In 2014, about 17% of physicians and 6% of nurses working in the 22 high-income countries that are members of the Organisation for Economic Co-operation and Development (OECD) had been trained in other countries.33 In the United States, 25% of physicians and 6% of nurses were trained in other countries. In Germany, the percentages were 9% and 6%, respectively. Hundreds of thousands of physicians and nurses trained in India, China, Iran, Nigeria, and other LMICs work

5.3  Access to Health Services

60

Iran 435 Brazil 105 China 318 India 415 Nigeria 498

Mental health workers per 100,000 people

USA 82 Germany 74

Ethiopia 3571

50

40

30

20

10

0 High income

Upper middle income

Lower middle income

Low income

FIGURE 5–4  Skilled health professionals (physicians, nurses, and nurse-midwives) in low- and middle-­ income countries must serve many more people than clinicians in high-income countries.

FIGURE 5–5  Mental health workers per 100,000 people.

Data from World health statistics 2016. Geneva: WHO; 2016.

Data from Mental health atlas 2014. Geneva: WHO; 2015.

20 Dentists per 10,000 people

15

10

5

U S er A m an y Ira n Br az i C l hi na In d N ia ig e Et ria hi op ia

0

G

in OECD countries.33 This means that LMICs bear the cost of training these clinicians, and high-­income countries reap the benefits of that investment in education. While it would be unethical to deny health professionals the opportunity to emigrate, it is problematic when skilled clinicians in countries with insufficient numbers of medical professionals are actively recruited by high-­income countries.34 The health SDGs will not be able to be met by 2030 if there is not a rapid expansion in the number of students enrolled in educational programs in medicine, nursing, and other health professions both in the ­lower-income countries that have the lowest clinician-per-population ratios as well as in the high-income countries that rely on foreign-born clinicians because they are not training enough clinicians within their own educational systems.35

105

FIGURE 5–6  Dentists per 10,000 people. Data from The challenge of oral disease: A call for global action. The oral health atlas. 2nd edition. Geneva: FDI World Dental Federation; 2015.

106

Chapter 5 Health and Humans Rights

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% High inome

Upper middle inome

Lower middle inome

Low inome

No access to surgery Access to surgery

FIGURE 5–7  Most people in low- and middle-income countries do not have timely access to safe and affordable surgery. Data from Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: A modelling study. Lancet Glob Health 2015;3:e316–23.

▸▸

5.4  Access to Medicines

Creating and testing new medications is a long and expensive process.36 New compounds must be created, tested in the laboratory, and then undergo several rounds of testing in humans. A clinical trial is a research study that evaluates the safety and effectiveness of a health intervention. A series of phase 1, 2, and 3 trials evaluate the safety and efficacy of the product in several thousand human volunteers.37 Candidate drugs that perform well in clinical trials are then submitted for governmental review. In the United States, it takes about 15 years and costs about $1.4 billion in expenditures to move a new product through the process of development, testing, and review by the Food and Drug Administration (FDA).38 It is similarly costly to move a new product from

discovery through the regulatory review process in Europe.39 In exchange for their research and development (R&D) investments, pharmaceutical companies with a newly approved product are granted a patent, the exclusive rights to sell the new product for at least 20 years (or other periods of time negotiated with governmental and intergovernmental agencies).40 This provides the company with a window of opportunity in which to recoup R&D costs and possibly make a profit. The World Trade Organization (WTO) is a UN-related organization that negotiates and enforces trade agreements among UN member nations.41 Three WTO-sponsored international agreements spell out the rules for trade in goods, services, and intellectual property: the General Agreement on Tariffs and Trade (GATT) that focuses on goods; the General Agreement on Trade in Services (GATS); and the Trade-Related Aspects of ­Intellectual Property Rights (TRIPS) Agreement, which protects patents, copyrights, registered trademarks, and industrial designs across national boundaries. Additional patent protections are provided to pharmaceutical and medical device companies through the World Intellectual Property Organization (WIPO) and some trade agreements between two or more countries. For example, trade agreements might extend the duration of a patent on a medication or device and enforce rules that prohibit generic versions of the products from being manufactured or imported. Having a highly regulated international pharmaceutical industry protects public safety. Licensed brand-name and generic medications are subject to strict manufacturing and packaging regulations that ensure the quality and safety of the product. A counterfeit drug is an illegal product that is marketed deceptively. For example, counterfeiters may package sugar pills in boxes with the name of a brand-name medication on them or they may repackage legally produced medicines that are past their expiration dates in containers with new dates that make it look like the pills were just manufactured.

5.4  Access to Medicines

© Adul10/Shutterstock

Some counterfeit products are both ineffective and unsafe because they do not contain any active pharmaceutical agent but might contain dangerous contaminants. A rigorous approval process for medications and devices ensures the quality and safety of licensed products. However, trade agreements that regulate pharmaceutical products may restrict the ability of LMICs to legally produce or procure low-cost versions of medications. A generic drug is a medication with the same active ingredient as a brand-name medication that is produced after the patent for the brand-name medication expires. Generic medications usually cost less than brand-name ones, but generics cannot be sold legally until after the expiration of the exclusivity period granted to the patent recipient. An essential medication is a drug that has been identified as a high priority for a country’s health system to have in stock at all times because it is a cost-effective treatment for a common health issue.42 Concerns about access to essential medications in LMICs became a prominent global health issue as the HIV/AIDS epidemic expanded in the 1990s. New antiretroviral medications (ARVs) that were saving lives in high-income countries were too expensive to be widely dispensed in LMICs. Countries like Brazil, India, and South Africa that tried to produce generic versions of patented ARVs or that imported generic medications produced elsewhere faced penalties for violating international intellectual property regulations.43 In the early

107

2000s, pharmaceutical companies, governmental health agencies, and advocacy groups worked together to make patented medications available at lower prices in LMICs. The 2001 Doha Declaration clarified the relationship between TRIPS and public health, noting that the TRIPS Agreement “does not and should not prevent members from taking measures to protect public health,” that “the Agreement can and should be interpreted and implemented in a manner supportive of WTO members’ right to protect public health and, in particular, to promote access to medicines for all,” and that countries facing a “national emergency or other circumstances of extreme urgency” could issue “compulsory licenses” for medications to be manufactured locally.44 This has helped increase legal access to critical medications, but significant inequalities in access to medications remain.45 The WHO core list of essential medicines that healthcare systems should stock includes about 400 anti-infective, anti-allergic, analgesic, antipsychotic, and hormonal drugs along with medications for noncommunicable diseases such as epilepsy, migraines, heart disease, asthma, and gastrointestinal diseases.42 In most low-income countries, the national formulary includes fewer than those 400 medications. In most high-income countries, more than 1000 additional products are on the list of approved and available medications.46 People in high-income countries spend much more each year on medicines per person (public and private spending combined) than people in LMICs. The typical person in the United States (or his/her health insurance provider) spends about $1000 on pharmaceutical products each year. By contrast, annual spending on medication is only $12 per person in India, $6 in Nigeria, and $5 in Ethiopia (FIGURE 5–8).47 The ethical principle of distributive ­justice posits that needed resources in a population should be fairly allocated. The right to health in the Universal Declaration of Human Rights implies that signatories have an ethical responsibility to expand the availability of

108

Chapter 5 Health and Humans Rights

USA $970

Germany $667

medications for diseases that for-profit companies are unlikely to invest in because of the limited revenue expected from a product created primarily for use in LMICs.49 When these partnerships are funded by governments or philanthropic organizations, the medications they produce can be made available at an affordable price as soon as they are proven to be safe and effective. Other types of partnerships work to accelerate the time line for making existing vaccines, diagnostic tools, and medicines legally available at affordable prices in LMICs.50

Iran $24 Brazil $128 China $72 India $12 Nigeria $6 Ethiopia $5

FIGURE 5–8  High-income countries spend much more on pharmaceutical products per person each year than lower-income countries (2014). Data from The pharmaceutical industry and global health: Facts and figures 2017. Geneva: International Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2017.

vaccines, diagnostic tests, and medicines that are free or affordable for people who live in low-­ income countries.48 This value is expressed in the SDG target that aims to “support the research and development of vaccines and medicines for the communicable and non-­communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use the full provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all” (SDG 3.b).10 One model for achieving this goal is the creation of public– private partnerships that target development of

▸▸

5.5  Health and Natural Disasters

Both natural and human-generated disasters can lead to urgent humanitarian situations (FIGURE 5–9). The critical needs immediately after any humanitarian incident include (1) water, sanitation, and hygiene; (2) food; (3) shelter and essential nonfood items, such as personal care items, clothing, bedding, cooking and eating utensils, fuel, and lighting; and (4) essential health services for injuries, infections, sexual and reproductive health, mental health, and noncommunicable diseases.51 The players involved in a particular humanitarian response depend on the scale of the incident (FIGURE 5–10).52 A crisis is a small-scale event that can easily be addressed locally, like when a tornado damages several homes in a small town and neighbors provide aid to the affected households. An emergency is a larger event that stresses local resources but can still be managed locally. A disaster occurs when the need for assistance exceeds local capacity. The type of response is also dependent on whether an incident affects just a small community or is an international event (FIGURE 5–11).53 A catastrophe overwhelms the local response network and requires extensive outside assistance.54 A well-managed international response to a natural disaster or catastrophe begins when

5.5  Health and Natural Disasters

Natural Disasters

Human-Generated Disasters

Weather-related disasters

Intentional

■■ ■■ ■■ ■■ ■■

Floods Landslides/mudslides Hurricanes/cyclones/typhoons Tornadoes Winter storms

Geophysical disasters ■■ ■■ ■■

■■ ■■ ■■

■■ ■■ ■■ ■■

War Genocide/ethnic cleansing Terrorism Refugee crises Internally displaced person crises

Unintentional

Earthquakes Tsunamis Volcanic eruptions

■■ ■■ ■■ ■■

Climate-related disasters ■■

■■

109

Droughts Extreme heat Extreme cold Wildfires and forest fires

■■ ■■

Transportation accidents Industrial accidents Hazardous materials spills Explosions/fires Radiation Structural collapses (buildings, bridges, dams, and tunnels)

Biological disasters ■■ ■■

Pandemic disease Insect infestations

FIGURE 5–9  Examples of types of disasters. 1

Crisis

Capacity > demand

Local response is sufficient

2

Emergency

Capacity = demand

Local response is sufficient

3

Disaster

Demand > capacity

Outside assistance is necessary

4

Catastrophe

Demand >> capacity

Extensive outside assistance is necessary

FIGURE 5–10  The scale of critical incidents depends on capacity and demand. Data from Quarantelli E.L. Just as a disaster is not simply a big accident, so a catastrophe is not just a big disaster. J Am Soc Prof Emerg Planners 1996;3:68–71.

an affected country invites the United Nations and other organizations to assist. A lead agency, usually the UN Office for the Coordination of Humanitarian Affairs (OCHA), is designated to coordinate the response by other UN agencies, government agencies (including militaries), the national Red Cross or Red Crescent society, and nongovernmental organizations. These groups work together to meet essential needs that have been designated as humanitarian response “clusters” (FIGURE 5–12).55 National and local responses

benefit from similar coordination strategies. In the United States, for example, the National Incident Management System (NIMS) specifies how different governmental agencies and nongovernmental organizations work together to respond to a disaster, and the Incident Command System (ICS) is an organizational structure used in the field to provide a clear chain of command for responders. The national response plan also identifies 15 Essential Support Functions (ESFs), critical service areas that require immediate attention

110

Chapter 5 Health and Humans Rights

PICE Stage

Potential for Additional Casualties

Effect on Local Resources

Extent of Geographic Involvement

Projected Need for Outside Assistance

0

Static

Controlled

Local

Little to none

Inactive

1

Dynamic

Disruptive

Regional

Small

Alert

2

Dynamic

Paralytic

National

Moderate

Standby

3

Dynamic

Paralytic

International

Great

Dispatch

Status of Outside Help

FIGURE 5–11  PICE (potential injury-creating event) nomenclature. Data from Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—a functional impact approach: The PICE system. Acad Emerg Med 1996;3:723–7.

Cluster

Lead UN Agency

Overall Coordination

OCHA

Technical Clusters

Camp coordination and management

IOM and UNHCR

Early recovery

UNDP

Education

UNICEF (and Save the Children)

Food security

WFP and FAO

Health

WHO

Nutrition

UNICEF

Protection

UNHCR

Shelter

IFRC and UNHCR

Water, sanitation, and hygiene

UNICEF

Emergency telecommunications

WFP

Logistics

WFP

Support Clusters

FIGURE 5–12  Humanitarian response clusters. Data from Stumpenhorst M, Stumpenhorst R, Razum O. The UN OCHA cluster approach: Gaps between theory and practice. J Public Health 2011;19:587–92.

5.5  Health and Natural Disasters

after a disaster, and names a lead agency that is responsible for each ESF during a disaster response (FIGURE 5–13).56 A coordinated response maximizes resources and saves lives. Interagency coordination helps facilitate a timely and comprehensive response, especially when this process ensures that volunteers and their host organizations complete appropriate training before traveling to the disaster site and are prepared to fully provide for themselves in the field.57 If the various

111

responders do not coordinate their efforts, the result can be chaos. In the weeks after the massive earthquake in Haiti in 2010, thousands of well-intentioned volunteers flew to Port-­auPrince to assist. Many of these spontaneous volunteers were unaffiliated with a Haiti-based host organization and arrived without adequate personal supplies, so they ended up being a burden rather than a help.58 Supplies remained stockpiled at the airport because the Haitian government, local institutions,

ESF #1

Transportation

ESF #2

Communications

ESF #3

Public works and engineering

ESF #4

Firefighting

ESF #5

Emergency management

ESF #6

Mass care, emergency assistance, housing, and human services

ESF #7

Logistics management and resource support

ESF #8

Public health and medical services

ESF #9

Search and rescue

ESF #10

Oil and hazardous materials response

ESF #11

Agriculture and natural resources

ESF #12

Energy

ESF #13

Public safety and security

ESF #14

Long-term community recovery

ESF #15

External affairs

FIGURE 5–13  Essential support functions (ESFs) in the National Incident Management System (NIMS) of the United States. Data from National incidence management system. Washington U.S. Department of Homeland Security; 2008.

112

Chapter 5 Health and Humans Rights

© Stefano Ember/Shuttertstock

and various international governmental and nongovernmental organizations had difficulty communicating about on-the-ground needs, securing local transportation, and coordinating distribution efforts. Similar logistical issues have occurred after other large-scale natural disasters, including the devastating tsunami that hit Southeast Asia in 2004.59 The SDGs address disaster preparedness and response in several targets, including a recognition of the need to “strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction, and management of national and global health risks” (SDG 3.d) (FIGURE 5–14).10 Mitigating risks and preparing for potential critical incidents before they happen are the best ways to enable a smooth response and recovery when a natural or human-generated disaster does occur. The Sendai Framework for Disaster Risk Reduction is a global agreement that aims to significantly diminish the number of deaths and the magnitude of destruction caused by natural disasters.60 The priority areas with the Sendai Framework include increasing awareness of disaster risks, strengthening emergency management capacities in all countries, promoting investment in risk reduction, and enhancing the effectiveness of response and recovery efforts, including ensuring that the rebuilt structures are more resilient to future hazardous events.61 The need for improved disaster preparedness is especially acute in lower-income countries.

Emergency management is about more than just responding to crises.62 Emergency management, also called disaster management, oversees all resources and responsibilities related to emergencies and disasters, including prevention, preparedness, response, and recovery. The emergency management cycle includes four steps, sometimes called the “4 Rs” (FIGURE 5–15): (1) Reduction of risks, or mitigation, is the process of implementing preemptive measures to protect people and property from hazards, such as by enforcing building codes. These activities enhance resilience, the ability of a community or nation to resist, survive, adapt to, and recover from natural disasters and other adverse events. (2) Readiness, or preparedness, for responding to an emergency includes the creation and refinement of emergency operations plans, the establishment of emergency communication infrastructure, and the training of public employees and emergency response volunteers. (3) Response to an imminent, ongoing, or recent threat includes provision of emergency medical assistance, shelter, and other critical services. (4) Recovery is a phase in which continued efforts focus on rebuilding affected communities and attending to other aspects of reconstruction and rehabilitation.

▸▸

5.6  Conflict and War

A complex humanitarian emergency occurs when civil conflict or war causes mass migration of civilian populations, food insecurity, and long-term public health concerns.63 Natural disasters usually create an immediate period of acute need but quickly transition into recovery mode. By contrast, complex humanitarian emergencies may remain in an acute phase for years or even decades. Because natural disasters are generally seen as apolitical events, it is usually fairly easy for aid agencies to assist survivors. Responses to complex humanitarian emergencies are much more complicated because military commanders

5.6  Conflict and War

113

1.5

Build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate-related extreme events and other economic, social, and environmental shocks and disasters.

2.4

Ensure sustainable food production systems and implement resilient agricultural practices that … strengthen capacity for adaptation to climate change, extreme weather, drought, flooding, and other disasters.

9.1

Develop quality, reliable, sustainable, and resilient infrastructure.

11.5

Significantly reduce the number of deaths and the number of people affected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations.

11.b

Substantially increase the number of cities and human settlements adopting integrated policies and plans toward inclusion, resource, efficiency, mitigation and adaptation to climate change, resilience to disasters, and develop and implement, in line with the Sendai Framework for Disaster Risk Reduction 2015–2030, holistic disaster risk management at all levels.

13.1

Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters in all countries.

16.1

Significantly reduce all forms of violence and related death rates everywhere.

FIGURE 5–14  SDG targets focused on disaster preparedness and response. Data from United Nations. Transforming our world: The 2030 agenda for sustainable development. New York: UN; 2015.

Recovery

Response

Reduction (Mitigation)

Readiness (Preparedness)

FIGURE 5–15  Four stages of the emergency management cycle.

and faction leaders engaged in armed conflicts are often disinclined to allow outsiders to assess and assist vulnerable populations.64 Numerous public health challenges arise during complex emergencies. The breakdown of water and sanitation systems and public health services may lead to frequent outbreaks of communicable diseases. Diarrheal diseases may become very common. V ­ accine-preventable diseases such as measles and meningitis may resurge when routine childhood vaccination programs are interrupted. Respiratory infections like pneumonia and tuberculosis may become more prevalent due to inadequate shelter. Other infectious disease concerns include the intensification of malaria in endemic areas, outbreaks of viral hepatitis, and an increased incidence of sexually transmitted infections,

114

Chapter 5 Health and Humans Rights

which may be spread through gender-based violence and then remain untreated because of lack of access to health care.65 International humanitarian laws are supposed to protect civilians and combatants,66 but these rules are not always enforced.67 Rape and sexual violence have been used as military tactics in many conflicts.68 Reproductive health services, including family planning and obstetric care, and psychiatric services tend to be severely inadequate during conflicts. Malnutrition is also a major concern during war and civil conflicts.69 Food production tends to decrease as farms are abandoned, and it is more difficult to import affordable food during times of instability. Food supply chains that enable food products to be processed, transported, stored, and sold are often interrupted by conflict and uncertainty. Large numbers of people may be migrating and in need of a daily supply of nutrients. The combination of too few calories, vitamins, and minerals plus lack of care for other diseases often leads to severe undernutrition. Two of the most prominent organizations involved in providing health services and other types of assistance during times of war are the Red Cross and Médecins Sans Frontières. The International Committee of the Red Cross (ICRC) is unique among private organizations because it is an independent organization guided by its own set of rules and principles—humanity, impartiality, neutrality, independence, voluntary service, unity, and universality—but it is officially sanctioned by the Geneva Convention and international law to provide specific humanitarian services.70 The ICRC works with more than 185 national Red Cross and Red Crescent societies and the International Federation of Red Cross and Red Crescent Societies to provide humanitarian aid to both civilian and military victims of conflicts. Red Cross representatives visit prisoners of war, search for missing persons, transmit messages between separated family members, reunify dispersed families, monitor compliance with the international laws that pertain to armed

conflict, and provide basic services to civilians, such as food, water, and medical assistance. The ICRC is funded through governmental support, contributions from national Red Cross and Red Crescent societies, and private donations. National Red Cross and Red Crescent societies are autonomous from the ICRC, and they provide a variety of services that meet needs in their communities, such as maintaining blood banks, providing first aid training, and offering assistance to residents who have been affected by natural disasters. The ICRC and its affiliates generally attempt to maintain neutrality by carefully avoiding actions that could appear to take sides with any particular political party and by not releasing statements that could be construed as political.71 MSF plays a very different role in global health than the ICRC. Médecins Sans ­Frontières (MSF), more often called ­Doctors Without Borders in the United States, provides medical care to people harmed by violence no matter what the victims’ races, religions, and political affiliations are.72 MSF often sets up clinics in places that are so unstable that other organizations refuse to deploy resources to them.73 The core values of MSF include independence, impartiality, and bearing witness to violations of human rights.72 To MSF, impartiality does not mean silence.74 Impartiality means that all governmental agencies and other bodies are equally open to criticism from MSF when they engage in or allow injustices.75

© Joseph Sohm/Shutterstock

5.7 Bioterrorism

In postconflict areas (and also in areas that have been devastated by natural disasters), a diversity of local, national, and international organizations typically help with reconstruction by responding to urgent needs, assisting with long-term recovery, and helping to prevent future crises. Political and economic systems need to be rebuilt, and educational and social services need to be restored after a civil conflict or war. Postconflict areas also need to repair health systems (because of lost infrastructure and personnel, among other issues), expand access to physical rehabilitation and mental healthcare services, and address environmental health concerns. Contaminated environments often take longer to renovate than hospitals and clinics.76 For example, a landmine is a buried explosive device, and landmines and other unexploded ordnance buried during wartime remain hazards to workers, children, and communities long after the conflict is over. This means, among many other problems, that large tracts of potential farmland are unable to be cultivated because of the risk of encountering a mine while clearing a field. Most people who sustain landmine injuries are civilians. Children may have elevated risk of injuries because they do not know how to recognize explosive devices and may pick them up and even play with them. Landmines and other explosive remnants of war remain a concern in many parts of the world, killing thousands of civilians each year and seriously injuring thousands of others.77 Although it only costs a few dollars to purchase and plant a mine, it can cost thousands of dollars to safely remove one.78 The direct costs to injured individuals and their families can be very high when they must pay for surgery, a lengthy hospitalization, and a lifetime of assistive devices for people who survive with lost limbs, burn contractures, blindness, and other permanent disabilities. A prosthetic is a replacement body part, such an artificial leg or arm that might be used after a limb is lost in a landmine explosion. Even a low-tech prosthetic can be expensive, and children with

115

amputated limbs need to be refitted with new devices as they grow.79 Access to basic health care is considered to be a fundamental human right, but wars and civil conflicts often restrict access to health services and the foundational tools for health.80 International organizations can play a critical role in advocating for human rights, promoting health, and providing medical care during times of conflict and war. In postconflict areas, public health work can facilitate the transition back to peace by implementing initiatives that improve population health status and strengthen social connections across diverse populations.81

▸▸

5.7 Bioterrorism

Bioterrorism is the deliberate release of pathogens, chemicals, or other agents that can cause illness and possibly death of people, animals, or plants. Chemical and biological warfare are not new.82 During the Tartar siege of the city of Kaffa (now in the Ukraine) in the 14th century, the bodies of plague victims were catapulted over city walls to spark an epidemic. During the French and Indian War in the 1760s, the British army sent smallpox-infected blankets to American Indians who supported the French. During World War I, several European nations used biological agents against the livestock of enemies. What is new is that there are now more tools available for creating and spreading bioterror agents and the scale on which such acts can occur is much larger. A bioweapon may be selected because it produces severe disease or death, the target population is susceptible to the agent, and the target population has limited or no access to immunization or treatment. Additionally, a particular agent may be selected for use because it can be produced relatively easily and rapidly, it is relatively inexpensive, it is environmentally stable, it has a low infectious dose, it has a simple delivery mechanism (such

116

Chapter 5 Health and Humans Rights

as through air, water, or food), it is highly infectious, it has a desirable incubation period (either short so immediate disease is produced or longer so that the asymptomatic contagious stage is lengthy), and it causes disease that is difficult to diagnose.83 While the goal of some bioterrorists is to kill or seriously injure large numbers of people, the most common goal is to cause widespread fear, panic, and social disruption. In the United States, potential bioterror agents are classified into three groups ­(FIGURE 5–16).84 Category A represents high-­ priority agents that pose a significant risk because they can be easily transmitted from one person to another or have high mortality rates. Category A agents include anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fevers like Ebola and Marburg virus. Anthrax (Bacillus anthracis) is of particular

Category

Agents

Category A

■■ ■■ ■■ ■■ ■■ ■■

Category B

Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Plague (Yersinia pestis) Smallpox (variola major) Tularemia (Francisella tularensis) Viral hemorrhagic fevers (such as Ebola, Marburg, Lassa, and Machupo viruses)

■■

Brucellosis (Brucella species) Glanders (Burkholderia mallei) Melioidosis (Burkholderia pseudomallei) Psittacosis (Chlamydia psittaci) Q fever (Coxiella burnetii) Toxins (such as ricin, Staphylococcus enterotoxin, and the epsilon toxin of Clostridium perfringens) Typhus fever (Rickettsia prowazekii) Food- and waterborne diseases (such as Cryptosporidium parvum, Escherichia coli O157:H7, hepatitis A virus, Salmonella, Shigella, and Vibrio cholerae) Mosquito-borne encephalitis viruses

■■

Emerging infectious diseases, including drug-resistant pathogens

■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

Category C

concern because the bacterium was used in a postal bioterrorism attack in the United States in 2001.85 Naturally occurring cases of anthrax are diagnosed every year in people who work with sheep and livestock because anthrax spores (dormant bacteria) can survive in the environment for years. These cases are usually cutaneous (skin) infections. In the laboratory, anthrax can be made into a fine powder that can cause an inhalational anthrax that affects the lungs. Anthrax is not passed from person to person, but the weaponized form can be aerosolized and breathed in.86 Anthrax disease can be cured with antibiotics if is detected early, but advanced cases are often fatal. ­Category B agents are moderately easy to spread but usually cause relatively few deaths. Examples of Category B agents include brucellosis, ricin (a toxin from the plant Ricinus communis, also known as castorbean or caster

FIGURE 5–16  U.S. classifications of potential bioterrorism agents. Data from Rotz LD, Khan AS, Lillibridge SR, Ostroff SM, Hughes JM. Public health assessment of potential biological terrorism agents. Emerg Infect Dis 2002;8:225–30.

5.7 Bioterrorism

oil plants), Q fever, typhus fever, viral encephalitis infections, food safety threats, such as Salmonella, Shigella, and E. coli O157:H7, and water supply threats, such as cholera and cryptosporidiosis. Category C agents are emerging infectious diseases like hantaviruses that are potential threats in part because they are not well understood. Chemical agents may also pose a threat (FIGURE 5–17).87 The best defense against a bioterrorism attack is early detection so that an outbreak can be contained and exposed or at-risk people can receive immunization, ­post-exposure prophylaxis, and medical treatment. This requires

117

a strong laboratory network, trained public health departments that are prepared to coordinate response activities, the cooperation of healthcare providers and emergency responders, and an adequate stockpile of essential vaccines and medications.84 Strong communication systems are also necessary for keeping the public informed of developments and encouraging appropriate personal responses. Global communication may also play a role in preventing some acts of terrorism and responding to attacks that do occur. In any response, careful attention must be paid to protecting the civil, political, economic,

Category

Examples

Nerve agents

Tabun, sarin, soman, GF, VX

Blood agents

Hydrogen cyanide, cyanogen chloride

Blister agents

Lewisite, nitrogen and sulfur mustards, phosgene oxime

Heavy metals

Arsenic, lead, mercury

Volatile toxins

Benzene, chloroform, trihalomethanes

Pulmonary agents

Phosgene, chlorine, vinyl chloride

Incapacitating agents

BZ

Explosive nitro compounds and oxidizers

Ammonium nitrate combined with fuel oil

Flammable industrial gases and liquids

Gasoline, propane

Poisonous industrial gases, liquids, and solids

Cyanides, nitriles

Corrosive industrial acids and bases

Nitric acid, sulfuric acid

Other agents

Esticides, dioxins, furans, polychlorinated biphenyls

FIGURE 5–17  Possible chemical bioweapons. Data from Biological and chemical terrorism: Strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep. 2000;49(RR-1):1–14.

118

Chapter 5 Health and Humans Rights

social, and cultural rights of affected persons. In some situations, individual and collective rights must be balanced. A nonderogable right is a human right that is irrevocable, such as the rights to freedom from slavery and freedom from torture. But some other rights may be temporarily suspended under special circumstances when restrictions on some individual rights protect the community as a whole. For example, freedom of movement for people with highly contagious infections may be temporarily limited during an outbreak so that the health rights of other people can be protected.88 If rights are derogated during or immediately after a critical incident, the new rules must not be discriminatory, and full rights should be restored as soon as possible.

▸▸

5.8  Health in Prisons

On any given day, nearly 10 million people across the globe are incarcerated, including more than 2.2 million people in the United States and 1.7 million in China (FIGURE 5–18).89 The incarceration rate varies considerably between countries, but the country with the highest rate, by far, is the United States

(FIGURE 5–19).89 Prisons, jails, and detention centers house convicted criminals and may also accommodate suspects waiting for trial, juvenile offenders, and undocumented immigrants. Many people entering prison already have health problems related to mental illness, drug abuse, and poverty. Incarceration may exacerbate existing health conditions and create new health problems as a result of exposure to severe overcrowding, poor ventilation, poor nutrition, unhygienic conditions, lack of access to medical care, abuse by guards, and prisoner-on-­prisoner violence, including beatings and sexual assault. Prison populations worldwide have higher rates of HIV, tuberculosis, and other infectious diseases than the general population.90 Tuberculosis (TB) is of particular concern because it is an airborne infectious disease. TB spreads easily in crowded prison blocks, and late diagnosis and inadequate treatment may allow prisoners with TB to remain contagious for lengthy periods of time. Interruptions in treatment can facilitate the emergence and spread of drug-resistant strains that are not able to be cured by the standard antibiotics used

2,217,000 USA

63,628 Germany 225,624 Iran

4,999,133 Rest of the world 1,657,812 China

607,731 Brazil

Prison population per 100,000 people

700 600 500 400 300 200

global average

100

111,050 Ethiopia

56,620 Nigeria

418,536 India

G US er A m an y Ira n Br az C il hi na In N dia ig Et eria hi op ia

0

FIGURE 5–18  More than 10 million people worldwide are in prison each day.

FIGURE 5–19  The United States has the world’s highest incarceration rate.

Data from Walmsley R. World prison population list. 11th ed. London: International Centre for Prison Studies; 2016.

Data from Walmsley R. World prison population list. 11th ed. London: International Centre for Prison Studies; 2016.

5.9  People with Disabilities

© txking/Shutterstock

to treat TB. Over time, an increase in TB in prisons will increase the amount of TB in the general population. When individuals infected with TB are released from prison, they may spread TB to their family and friends. To prevent further increases in the prevalence of TB in prisons, it is important for every case of TB in incarcerated people to be detected early and treated consistently with no interruptions in ­antibiotic therapy.91 Prisoners are entitled to all fundamental human rights, and they have a right to be protected from medical neglect, starvation, abuse, forced medical experimentation, and other civil rights violations.92 Contracting potentially life-threatening infections is not part of any prisoner’s sentence. It is considered unjust not to provide incarcerated people with medical and dental care, adequate nutrition, protection from infectious diseases, and safe conditions.93

▸▸

5.9  People with Disabilities

An impairment is a difference or limitation in an anatomical structure, mental or sensory function, or physiological function that constrains the capacity of an individual to do a task or action. A disability occurs when an impairment leads to restrictions in activity and participation. Disability is the result of both an

119

impairment and the social and environmental context in which a person with impairment interacts with other people and the world (FIGURE 5–20). About 15% of the world’s people—more than 1 billion people total—have a moderate or severe disability.94 People with disabilities are entitled to all of their human rights, including the right to be treated with dignity, to have the autonomy to make decisions for themselves (if they are cognitively capable of doing so), and to be active members of society.95 An impairment may affect numerous domains, such as self-care, mobility, communication, and learning (FIGURE 5–21).96 Some people with impairments need assistance with activities of daily living (ADLs), the routine daily self-care functions that are required for health and survival, such as dressing, eating, ambulating, using the toilet, and taking care of personal hygiene (FIGURE 5–22). Some people with impairments can manage the ADLs but require assistance with the instrumental activities of daily living (IADLs) required for independent living, such as shopping, housekeeping, managing personal finances, preparing foods, and navigating transportation. Some people with impairments manage their own ADLs and IADLs, but experience limitations in full participation in social events because of stigma and other barriers. Rehabilitation is the process of restoring, improving, or maintaining the highest Impairment of body structures (anatomy) or functions (physiology)

Personal and social factors

Environmental factors

Activity limitations and participation restrictions

FIGURE 5–20  Disabilities are a function of biological, social, and environmental factors.

120

Chapter 5 Health and Humans Rights

Domain

Activities

Learning and applying knowledge

Watching, listening, learning to read, learning to write, learning to calculate, solving problems

General tasks and demands

Undertaking a single task, undertaking multiple tasks

Communication

Receiving spoken messages, receiving nonverbal messages, speaking, producing nonverbal messages, conversation

Mobility

Lifting and carrying objects, fine hand use (such as picking up objects or grasping them), walking, moving around using equipment (such as a wheelchair), using transportation

Self-care

Washing oneself (such as washing hands, bathing, and using a towel), caring for body parts (by brushing teeth, shaving, and grooming), toileting, dressing, eating, drinking, looking after one’s own health

Domestic life

Acquisition of goods and services (such as by shopping), preparation of meals (such as by cooking), doing housework (such as cleaning house, washing dishes, doing laundry, and ironing), assisting others

Interpersonal interactions and relationships

Basic interpersonal interactions, complex interpersonal interactions, relating to strangers, formal relationships, informal social relationships, family relationships, intimate relationships

Major life areas

Informal education, school education, higher education, remunerative employment, basic economic transactions, economic self-sufficiency

Community, social, and civic life

Community life, recreation and leisure, religion and spirituality, human rights, political life, and citizenship

FIGURE 5–21  Domains of activity and participation from the International Classification of Functioning, Disability, and Health. Data from International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO; 2001.

level of function possible in order to maximize independence and quality of life. Adults and children of all ages who have impairments can benefit from timely access to appropriate physical therapy, occupational therapy, speech–language therapy, and other types of rehabilitation services.97 A condition that might be preventable or treatable in a

­ igh-income country where rehabilitation h facilities are routinely accessible might cause permanent disability in a low-income country where rehabilitation services are not available. People with physical and mental impairments and disabilities also benefit from being included to the fullest extent possible in the activities of their families and communities.

5.9  People with Disabilities

Activities of Daily Living (ADLs): Self-care

Instrumental Activities of Daily Living (IADLs): Independence

Dressing

Shopping

Eating

Housekeeping

Ambulating (mobility)

Accounting (personal finances)

Toileting

Food preparation

Hygiene

Transportation

121

FIGURE 5–22  Activities of daily living.

People with impairments may have their activities facilitated or restricted by their environment and the resources available to them. An assistive device, also called assistive technology, is a tool that helps with the performance of a task. Assistive devices such as wheelchairs and canes, prosthetics for people with missing arms or legs, orthotics and braces for people with various types of musculoskeletal disorders, hearing aids, and glasses can enable independence and fuller participation in social activities. However, only about 10% of people worldwide who would benefit from medical assistive devices have them.98 A person who uses a wheelchair may easily access public transportation, sidewalks, and public buildings in Germany, but might find it impossible to navigate the unpaved pathways of rural Ethiopia. An American with a visual impairment may have access to books through Braille editions, electronic magnifiers, and audio recordings, but a similarly impaired person in Nigeria might not have access to any of these tools. The SDGs feature numerous targets geared toward increasing the ability of people with disabilities to access social protections (SDGs 1.3 and 10.2), education (SDGs 4.5 and 4.a),

CDC/Molly Kurnit, M.P.H./Paul Chenoweth

work (SDG 8.5), transportation (SDG 11.2), public spaces (SDG 11.7), and civic events (SDG 16.7).99 People with disabilities have an increased risk of living in poverty. The direct costs associated with paying for medical care and assistance can be overwhelming. Health issues restrict the ability of some people with disabilities to work, and family caregivers may need to limit their paid employment and home productivity. These economic factors are exacerbated when people with disabilities have limited access to the public services, education, and employment opportunities that would enable a higher standard of living. A safe and accessible physical environment and a strong social network are critical for maximizing the activities and social participation of all people who have impairments and disabilities (FIGURE 5–23).96

122

Chapter 5 Health and Humans Rights

Environment

Environmental Characteristics

Products and technology

Products for personal consumption (food, medicines), for personal use in daily living, for personal indoor and outdoor mobility and transportation, for communication; design, construction, and building materials of buildings for public use and buildings for private use

Natural environment and human-made changes to the environment

Climate, light, sound

Support and relationships

Support of and relationships with immediate family, friends, acquaintances, peers, colleagues, neighbors, community members, people in positions of authority, personal care providers and personal assistants, healthcare professionals

Attitudes

Individual attitudes of immediate family members, friends, personal care providers and personal assistants, healthcare professionals; societal attitudes; social norms, practices, and ideologies

Services, systems, and policies

Services, systems, and policies related to housing, communication, transportation, legal, social, health, education and training, labor and employment

FIGURE 5–23  Environmental characteristics that relate to activities and participation. Data from International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO; 2001.

The WHO defines health as “a state of complete physical, mental, and social well-being.”1 By that definition, any action that improves social well-being will improve overall health status. Increasing the social inclusion of people with disabilities will yield health benefits for those individuals and their families, and also for their communities. Global health is founded on the principle that all people have the right to the highest attainable standard of health. Advocating for everyone’s human rights is a core part of achieving that shared goal.

▸▸

References

1. Constitution of the World Health Organization. New York: United Nations; 1946. 2. The Universal Declaration of Human Rights. New York: United Nations; 1948.

3. Leckie S. Another step towards indivisibility: Identifying the key features of violations of economic, social and cultural rights. Human Rights Q. 1998;20:81–124. 4. Hunt P. The human right to the highest attainable standard of health: New opportunities and challenges. Trans R Soc Trop Med Hyg. 2006;100:603–7. 5. International Covenant on Economic, Social and Cultural Rights (A/RES/21/2200). New York: UN; 1966. 6. Mann JM, Gostin LO, Gruskin S, Brennan T, Lazzarini Z, Fineberg HV. Health and human rights. Health Hum Rights. 1994;1:6–23. 7. Global health ethics: Key issues. Geneva: WHO; 2015. 8. Farmer P. Pathologies of power: Rethinking health and human rights. Am J Public Health. 1999;89:1486–96. 9. Gostin LO, Friedman EA, Ooms G, et al. The joint action and learning initiative: Towards a global agreement on national and global responsibilities for health. PLoS Med. 2011;8:e1001031. 10. United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. New York: UN; 2015.

References 11. Gliek PH. The human right to water. Water Policy. 1998;1:487–503. 12. Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003. 13. Bleumel EB. The implications of formulating a human right to water. Ecol Law Q. 2004;31:957–1006. 14. Nickson A, Vargas C. The limitations of water regulation: The failure of the Cochabamba concession in Bolivia. Bull Latin Am Res. 2002;21:99–120. 15. Morgan. Water: Frontier markets and cosmopolitan activism. Soundings J Polit Nat. 2004;28:10–24. 16. Mirosa O, Harris LM. Human right to water: Contemporary challenges and contours of a global debate. Antipode. 2012;44:932–49. 17. Jones PA, Moulton A. The invisible crisis: Water unaffordability in the United States. Cambridge MA: Unitarian Universalist Service Committee (UUSC); 2016. 18. Markel H. Remember flint. Milbank Q. 2016;94:229–36. 19. Hundley N Jr. Water and the West: The Colorado River compact and the politics of water in the American West. Los Angeles CA: University of California Press; 2009. 20. Glennon R. Water scarcity, marketing, and privatization. Texas Law Rev. 2005;83:1873–902. 21. United Nations Committee on Economic, Social and Cultural Rights. General Comment 14: The right to the highest attainable standard of health (E/C 12/2000/4). Geneva: UN Office for the High Commissioner for Human Rights; 2000. 22. Spiegelhalter DJ, Gore SM, Fitzpatrick R, Fletcher AE, Jones DR, Cox DR. Quality of life measurements in health care. III: Resource allocation. BMJ. 1992;305:1205–9. 23. A universal truth: No health without a workforce. Geneva: WHO/Global Health Workforce Alliance (GHWA); 2014. 24. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff. 2008; 27:759–69. 25. Marten R, McIntyre D, Travassos C, et al. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). Lancet. 2014;384:2164–71. 26. Health workforce requirements for universal health coverage and the Sustainable Development Goals. Geneva: WHO; 2016. 27. World health statistics 2016. Geneva: WHO; 2016. 28. Mental health atlas 2014. Geneva: WHO; 2015. 29. The challenge of oral disease: A call for global action. The oral health atlas. 2nd ed. Geneva: FDI World Dental Federation; 2015. 30. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.

123

31. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: A modelling study. Lancet Glob Health. 2015;3:e316–23. 32. Taylor AL, Hwenda L, Larsen BI, Daulaire N. Stemming the brain drain: A WHO Global Code of Practice on International Recruitment of Health Personnel. N Engl J Med. 2011;365:2348–51. 33. Dumont J, Lafortune G. International migration of doctors and nurses to OECD countries: Recent trends and policy implications. Geneva: WHO High-Level Commission on Health Employment and Economic Growth; 2016. 34. User’s guide to the WHO Global Code of Practice on the International Recruitment of Health Personnel. Geneva: WHO; 2010. 35. Global strategy on human resources for health: Workforce 2030. Geneva: WHO; 2016. 36. The pharmaceutical industry and global health: Facts and figures 2017. Geneva: International Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2017. 37. Good review practice: Clinical review of investigational new drug applications. Silver Spring MD: U.S. Food and Drug Administration (FDA); 2013. 38. DiMasi JA, Grabowski HG, Hansen RW. Innovation in the pharmaceutical industry: New estimates of R&D costs. J Health Econ. 2016;47:20–33. 39. Van Norman GA. Drugs and devices: Comparison of European and U.S. approval processes. JACC Basic Transl Sci. 2016;1:399–412. 40. Managing access to medicines and health technologies (MDS-3). Arlington VA: Management Sciences for Health (MSH); 2012. 41. Fidler DP, Drager N, Lee K. Managing the pursuit of health and wealth: The key challenges. Lancet. 2009;373:325–31. 42. WHO model list of essential medicines (19th list). Geneva: WHO; 2015. 43. ‘t Hoen E, Berger J, Calmy A, Moon S. Driving a decade of change: HIV/AIDS, patents and access to medicines for all. J Int AIDS Soc. 2011;14:15. 44. World Trade Organization (Doha WTO Ministerial 2001). Declaration on the TRIPS agreement and public health (WT/MIN(01)/DEC/2); 2001. 45. Smith RD, Correa C, Oh C. Trade, TRIPS, and pharmaceuticals. Lancet. 2009;373:684–91. 46. van den Ham R, Bero L, Laing R. Selection of essential medicines. In: The world medicines situation 2011. 3rd ed. Geneva: WHO; 2011. 47. The pharmaceutical industry and global health: Facts and figures 2015. Geneva: International Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2015. 48. Lee JY, Hunt P. Human rights responsibilities of pharmaceutical companies in relation to access to medicines. J Law Med Ethics. 2012;40:220–33.

124

Chapter 5 Health and Humans Rights

49. Howitt P, Darzi A, Yang GZ, et al. Technologies for global health. Lancet. 2012;380:507–35. 50. Access to medicine index 2016. Haarlem, Netherlands: Access to Medicine Foundation; 2016. 51. The Sphere Project. Humanitarian charter and minimum standards in humanitarian response. 3rd ed. Rugby UK: Practical Action Publishing; 2011. 52. Quarantelli EL. Just as a disaster is not simply a big accident, so a catastrophe is not just a big disaster. J Am Soc Prof Emerg Planners. 1996;3:68–71. 53. Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—A functional impact approach: The PICE system. Acad Emerg Med. 1996;3:723–7. 54. Holguín-Veras J, Jaller M, Van Wassenhove LN, et al. On the unique features of post-disaster humanitarian logistics. J Oper Manag. 2012;30:494–506. 55. Stumpenhorst M, Stumpenhorst R, Razum O. The UN OCHA cluster approach: Gaps between theory and practice. J Public Health. 2011;19:587–92. 56. National Incident Management System. Washington DC: U.S. Department of Homeland Security; 2008. 57. Krin CS, Giannou C, Seppelt IM, et al. Appropriate response to humanitarian crises. BMJ. 2010;340: c562. 58. Jobe K. Disaster relief in post-earthquake Haiti: Unintended consequences of humanitarian volunteerism. Travel Med Infect Dis. 2011;9:1–5. 59. VanRooyen M, Leaning J. After the tsunami: Facing the public health challenges. N Engl J Med. 2005;352:435–8. 60. Aitsi-Selmi A, Egawa S, Sasaki H, Wannous C, Murray V. The Sendai framework for disaster risk reduction: Renewing the global commitment to people’s resilience, health, and well-being. Int J Disaster Risk Sci. 2015;6:164–76. 61. Sendai Framework for Disaster Risk Reduction 2015– 2030. Geneva: United Nations Office for Disaster Risk Reduction (UNISDR); 2015. 62. McLoughlin D. A framework for integrated emergency management. Public Admin Rev. 1985;45(Special Issue):165–72. 63. Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencies over past decade. Lancet. 2004;364:1801–13. 64. Spiegel PB. Differences in world responses to natural disasters and complex emergencies. JAMA. 2005;293:1915–18. 65. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health. 1997;18:283–312. 66. Melzer N. International humanitarian law: A comprehensive introduction. Geneva: ICRC; 2016. 67. Kalshoven F, Zegveld L. Constraints on the waging of war. 4th ed. Cambridge UK: Cambridge University Press; 2011.

68. Kivlahan C, Ewigman N. Rape as a weapon of war in modern conflicts. BMJ. 2010;340:c3270. 69. Young H, Borrel A, Holland D, Salama P. Public nutrition in complex emergencies. Lancet. 2004;364:1899–909. 70. The fundamental principles of the Red Cross and Red Crescent. Geneva: ICRC; 2016. 71. Minear L. The theory and practice of neutrality: Some thoughts on the tensions. Int Rev Red Cross. 1999;833. 72. International activity report 2015. 2nd ed. Geneva: MSF; 2016. 73. Hope in hell: Inside the world of Doctors Without Borders. 3rd rev. ed. Richmond Hill ON: Firefly Books; 2010. 74. Barnett M. Humanitarianism transformed. Persp Politics. 2005;3:723–40. 75. Redfield P. A less modest witness: Collective advocacy and motivated truth in a medical humanitarian movement. Am Ethnologist. 2006; 33:3–26. 76. Brown VJ. BattleScars: Global conflicts and environmental health. Environ Health Perspect. 2004;112:A994–1003. 77. Landmine monitor 2016. Geneva: International Campaign to Ban Landmines; 2016. 78. Machel G. Impact of armed conflict on children (report A/51/306). New York: United Nations; 1996. 79. Assistance to victims of landmines and explosive remnants of war: Guidance on child-focused victim assistance. New York: UNICEF; 2014. 80. Protecting health care: Key recommendation. Geneva: ICRC; 2016. 81. MacQueen G, Santa-Barbara J. Peace building through health initiatives. BMJ. 2000;321:293–6. 82. Noah DL, Huebner KD, Darling RG, Waeckerle JF. The history and threat of biological warfare and terrorism. Emerg Med Clin N Am. 2002;20:255–71. 83. Beeching NJ, Dance DAB, Miller ARO, Spencer RC. Biological warfare and bioterrorism. BMJ. 2002;324:336–9. 84. Rotz LD, Khan AS, Lillibridge SR, Ostroff SM, Hughes JM. Public health assessment of potential biological terrorism agents. Emerg Infect Dis. 2002;8:225–30. 85. Inglesby TV, O’Toole T, Henderson DA, et al. Anthrax as a biological weapon, 2002: Updated recommendations for management. JAMA. 2002;287:2236–52. 86. Jernigan DB, Raghunathan PL, Bell BP, et al. Investigation of bioterrorism-related anthrax, United States, 2001: Epidemiologic findings. Emerg Infect Dis. 2002;8:1019–28. 87. Biological and chemical terrorism: Strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep. 2000;49(RR-1):1–14.

References 88. Thompson AK, Faith K, Gibson JL, Upshur REG. Pandemic influenza preparedness: An ethical framework to guide decision-making. BMC Med Ethics. 2006;7:12. 89. Walmsley R. World prison population list. 11th ed. London UK: International Centre for Prison Studies; 2016. 90. Watson R, Stimpson A, Hostick T. Prison health care: A review of the literature. Int J Nurs Stud. 2004;41:199–28. 91. Dara M, Grzemska M, Kimerling ME, Reyes H, Zagorskiy A. Guidelines for control of tuberculosis in prisons. Washington DC: USAID; 2009. 92. Møller L, Stöver H, Jürgens R, Gatherer A, Nikogosian H, editors. Health in prisons: A WHO guide to the essentials in prison health. Copenhagen: WHO Europe; 2007.

125

93. Standard minimum rules for the treatment of prisoners. Geneva: Office of the United Nations High Commissioner for Human Rights; 1977. 94. World report on disability 2011. Geneva: WHO; 2011. 95. Convention on the Rights of Persons with Disabilities and optional protocol. New York: UN; 2006. 96. International Classification of Functioning, Disability, and Health (ICF). Geneva: WHO; 2001. 97. WHO Global Disability Action Plan 2014–2021: Better health for all people with disability. Geneva: WHO; 2014. 98. Priority assistive products list. Geneva: WHO; 2016. 99. United Nations Economic and Social Council. Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2016/2/ Rev.1). New York: UN; 2016.

© Xinzheng. All Rights Reserved/Moment/Getty

CHAPTER 6

Global Health Financing Health is a big business, with trillions of dollars spent annually on health services worldwide. Most individual and public health expenses in high-income countries are paid for with tax revenue or mandatory insurance plans that enable universal access to critical health services. In lower-income countries, people who are unable to pay out-of-pocket for health services may be denied access to clinical care. Global health activities financed with government funds from host and donor countries as well as by charitable contributions from philanthropies, businesses, and private donors facilitate improvements in health promotion and disease prevention in vulnerable populations.

126

pi a

hi o

Et

a

er ia

N ig

na

In di

hi

C

az i

l

global average

Ira n

Health expenditures are a significant component of the global economy, accounting for more than 8% of the world’s total gross domestic product (GDP) (FIGURE 6–1).1 The costs of health can be divided into two categories: (1) money spent on personal health and (2) money spent on public health. Personal health expenses relate to the health of one individual or family, such as the cost of purchasing antibiotics to treat a bacterial infection, paying for a midwife to help deliver a baby, or buying test strips for self-­monitoring of blood glucose levels by people with diabetes. Public health expenses relate to shared activities that protect a community, a nation, or the global population at large, such as the costs associated with

18 16 14 12 10 8 6 4 2 0

Br

6.1  Personal and Public Health

U G SA er m an y

▸▸

FIGURE 6–1  High-income countries spend a high percentage of their gross domestic product on health. Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.

127

6.1  Personal and Public Health

Missing/Excluded Less than 50 50 to 200 200 to 500 500 to 1500 1500 and above

FIGURE 6–2  Health spending per capita (2014). Data from Health system financing profile by country. Geneva: WHO Global Health Expenditure Database; 2017.

6000

Spending on health per person

investigating and containing outbreaks of infectious diseases, marketing the mass polio vaccination days that are part of the global eradication campaign, using insecticides in outdoor areas to kill the mosquitoes that can transmit dangerous pathogens to humans, and developing evidence-based clinical guidelines for managing chronic diseases. Worldwide, more than $9 trillion was spent on health care in 2015, and annual spending could increase to $16 trillion by 2030.2 High-­ income countries spend much more per resident on healthcare services than low-­income countries do (FIGURE 6–2). This difference remains significant even after adjusting for differences in the cost of living (­ FIGURE 6–3).1 There are a diversity of mechanisms for paying for personal health expenses. Some countries have a publicly funded healthcare system that is paid for with tax revenue, some have a healthcare system in which the medical care of individuals is usually funded by private health insurance or the personal funds of the

5000 4000 3000 2000 1000 0 High income

Upper Lower middle middle income income

Low

FIGURE 6–3  Total spending on health care per capita by country income level (2014). Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.

128

Chapter 6 Global Health Financing

individual and his or her family, and some countries pay for personal health services with a combination of public and private sources (FIGURE 6–4).3 Most public health activities in

FUNDERS Who pays?

higher-income countries are funded by taxes. Public health initiatives in lower-­income countries are often financed with a combination of governmental and external support.

PERSONAL HEALTH

PUBLIC HEALTH

Typical HIGH-income country

Governments (via taxes)

Governments (via taxes)

Typical LOW-income country

Households & others

Governments & donors

FIGURE 6–4  Governments in high-income countries use tax revenue to pay for most health services; in lowincome countries, a more diverse set of funders pay for health activities.

© Djohan Shahrin/Shutterstock

© fivepointsix/Shutterstock

© Pablo Rogat/Shutterstock

© Iakov Filimonov/Shutterstock

6.2  Health Systems

Financing is the provision of money for a particular activity and the management of that investment. Financing for global health is allocated to both personal and public functions. Some global health funding helps ­lower-income countries expand the personal healthcare services that they offer to residents. For example, some donors have provided financing that enables more women in ­low-income countries to give birth at hospitals at no cost to the family, more children to be treated for intestinal worm infections through school-based programs, and more people living with HIV to access free and lowcost antiretroviral medications. Some global health funding supports global health governance,4 pandemic preparedness and response, the development and dissemination of new health technologies, and other public health functions.5 There are also expenses that blend the personal and public health categories, like the costs associated with educating healthcare workers, ensuring that clinicians are licensed and staying up to date on best practices, and building and maintaining hospitals to ensure that everyone has access to essential health services. These activities are public health functions that enable individuals to have access to quality personal health care. All of these activities are part of functioning health systems.

▸▸

6.2  Health Systems

A health system includes all of the people, facilities, products, resources, and organizational structures that deliver health services to a population. The World Health Organization (WHO) has identified six core building blocks of health systems: (1) the provision of effective personal and population-based healthcare services; (2) a well-trained and productive health workforce that is able to provide quality care to all population groups; (3) a strong health information system that collects, analyzes, and disseminates the

129

information about population health and health systems performance that is critical for health system ­decision-making;6 (4) access to essential medicines, medical devices, vaccines, and other health technologies; (5) a health financing system that enables everyone to access affordable services when they are needed while providing incentives to limit overuse of services; and (6) effective oversight of the system to ensure safety, efficiency, and accountability.7 The Sustainable Development Goals (SDGs) aim by 2030 to “achieve universal health coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable medicines and vaccines for all” (SDG  3.8).8 Universal health ­coverage (UHC) is present when everyone in a country has access to high-quality health services (including preventive care, diagnosis, treatment, and rehabilitation) and everyone is protected from major health-associated financial shocks via a tax-based financing system or a health insurance plan.9 In places where patients and their families pay out-of-pocket for most health services, the poorest households are often excluded from accessing quality care. By contrast, countries that spread the cost of health services across the entire population through tax revenue or mandatory participation in highly regulated insurance plans enable everyone to access the services that are included in the national health plan (FIGURE 6–5).10 These services typically include family planning (contraception), obstetric and newborn care, child vaccines, medications for common infections and noncommunicable diseases (such as high blood pressure and diabetes), care for acute injuries, and other services that have been identified as population priorities.11 Every government has finite financial reserves, so it is not possible for national health systems to provide every procedure for every condition for every person. Government officials and other people with health leadership

130

Chapter 6 Global Health Financing

Source of Funds

Private

Mostly private

Mostly public

Public

Payment

Out-ofpocket

Private insurance

Social insurance/ sickness funds

General revenue (taxes)

Cost Burden

Coverage

Individuals

Increasingly pooled risk

Whole population

Poorest excluded

Increasingly equitable

Universal

FIGURE 6–5  Universal health coverage spreads the cost burden for health services across the entire population. Data from World health report 1999. Geneva: WHO; 1999.

responsibilities in countries aiming to achieve UHC must make difficult decisions about which goods and services will be provided to everyone. For example, health system leaders must decide which procedures will and will not be available in public hospitals and which medications will and will not be included in the national formulary. Resource limitations may mean that only part of a comprehensive strategy for improving population health status can be publicly funded. For example, budgeting authorities might determine that it is possible to improve access to in-hospital trauma care for injured people but there is not sufficient funding to simultaneously support injury prevention activities, train and equip more emergency responders, and provide more physical therapy and rehabilitation services for survivors. The decision to increase coverage for one type of service sometimes requires decreases in support for other types of health services. Government officials must also make critical determinations about how much funding can be allocated to the health system and how much must be dedicated to maintaining other necessary services. Increases

in government spending on health often require decreases in funding for education and other social services. Funding decisions have a very tangible impact on the quality of services that are provided. The governments of high-income countries with aging populations usually allocate more of their budget to health than to education.12 In these countries, surveys that ask residents about their perceptions of social services and their overall quality of life typically show that satisfaction with health services exceeds levels of satisfaction with the education system ­(FIGURE 6–6).13 The governments of low- and middleincome countries with a large proportion of children in their populations usually allocate more funding to education than to health. Surveys in these countries usually show a higher level of satisfaction with schools than with the healthcare system. Health system strengthening requires a process of identifying priorities and resources, strategizing about the policies that will achieve key goals, transforming those ideas into operational action plans, and then implementing changes and tracking progress toward meeting the targets.14

6.3  Paying for Personal Health

131

100%

% satisfied

80%

60%

40%

20%

0% Education quality

Health care quality USA

Germany

Iran

Brazil

China

Quality of life India

Nigeria

Ethiopia

FIGURE 6–6  Satisfaction with healthcare quality is highest in high-income countries. Data from World health statistics 2016. Geneva: WHO; 2016.

▸▸

6.3  Paying for Personal Health

Each country has a unique mix of strategies for paying for personal health expenses, but there are some general patterns by country income level (FIGURE 6–7).1 Most h ­ igh-income countries have a government-sponsored healthcare system that is paid for through general tax revenue, mandatory payments into a ­government-run social security system, or other types of compulsory contributions. Health services are typically provided at government health facilities or at private facilities that receive most of their funds from the ­government. (The health financing and delivery system in the United States is a notable exception to the general global trend for high-income countries.)

In most middle-income countries, governments pay for a portion of health costs but the remaining money spent on health is expended in the form of out-of-pocket (OOP) payments, cash disbursements made by patients and their families in order to receive health services (FIGURE 6–8).1 The range of services covered by government health plans vary widely. Some health systems pay for all the expenses of hospitalization for a range of causes, while others require the patient to pay part or most of the cost of a hospital stay. Some health systems require users to pay a fee at the time of service and pay OOP for prescription medications and therapy, while others do not. Only a few government health plans include dental care and vision care in their health packages. In places where private healthcare coverage is available to supplement government services, there are

Chapter 6 Global Health Financing

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

n

az il C hi na In di a N ig er Et ia hi op ia

Br

an y

Ira

Low

m

Lower middle income

U

Upper middle income

er

High income

SA

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

G

132

Out-of-pocket

Out-of-pocket

Prepaid private

Prepaid private

Development assistance for health (DAH) Domestic government

Development assistance for health (DAH) Domestic government

FIGURE 6–7  Total spending on health by payer and country income level. Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.

wide variations in the prices of private plans and differences in the quality of services covered by the plans. In most low-income countries, some basic clinical services that have been deemed necessary for achieving high-priority global health goals are financed by domestic governments and international donors to ensure that these services are available to everyone who needs them. For other health conditions, both public and private healthcare facilities may charge user fees and require additional OOP payments for medications and supplies.15 When subsidized healthcare services are unavailable or the quality of local health services is poor, families are often unable to access any type of skilled care. For example, in some low-income countries, all pregnant

FIGURE 6–8  Sources of funding for health in featured countries. (Prepaid private spending includes private insurance and spending by nongovernmental organizations.) Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.

women can give birth for free at public hospitals (if they can afford transportation to a hospital, which is not always possible for women who live in rural areas). In other low-income countries, women must pay OOP to give birth at a hospital or must pay midwives OOP to help deliver their babies at home. When families cannot afford to hire help, women must deliver at home without a trained birth assistant. Similarly, in some low-income countries, everyone with HIV can access free or low-cost antiretroviral medications, with the price tied to income to ensure free access to low-income individuals. However, in other countries, people from higher-income households who can afford the medications

6.4  Health Insurance

take them and those from lower-income households who cannot afford the medications do not take them. Increasing access to affordable health services for the most vulnerable populations is one of the major goals for health system strengthening in most low-­ income countries.

▸▸

133

develop a very serious chronic condition or suffer a catastrophic injury. However, because everyone is at risk of unexpected health crises, most people are willing to pay additional taxes or purchase insurance that protects them against the small possibility of needing to forego essential medical care because they cannot afford it or acquiring a lifetime of unmanageable, impoverishing debt as a result of one medical incident.16 The country that spends the most on health each year, by far, is the United States (FIGURE 6–9),1 which has a health system that is unique among high-income countries because it is not a universal health coverage system. Nearly all health services are provided in private facilities, and a mix of private insurance and government funding is used to pay for healthcare services. Pooled risk was at the core of the U.S. Patient Protection and Affordable Care Act (ACA) of 2010, which made participation in an insurance plan mandatory for those who could afford it and provided financial support for lower-income households to purchase private coverage or

6.4  Health Insurance

Insurance is a risk management strategy that protects purchasers against major financial losses. Health insurance is intended to protect insured people from incurring overwhelming expenses if they happen to develop an expensive health condition. Health insurance systems, whether private or public, are funded based on the principle of pooled risk. Pooled risk assumes that if many low-risk people and a few high-risk people all pay premiums to the insurance system over many years, there will be a pot of money that can be used to pay for major illnesses and injuries when they occur. Only a few people will 10000 1400

Spending on health per person

1200

8000

1000 800

6000

600 400

4000

200 0 Iran

2000

Brazil

China

India

Nigeria Ethiopia

0 USA

Germany

Iran

Brazil

China

India

Nigeria

Ethiopia

FIGURE 6–9  Total spending on health care per capita in featured countries (2014). Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.

134

Chapter 6 Global Health Financing

gain access to government-sponsored health coverage plans. The proportion of Americans who were uninsured decreased after the ACA insurance mandate went into effect in 2014, but the percentage of uninsured people did not reach 0%.17 In 2015, about 91% of Americans had health insurance coverage and 9% had no health insurance.17 Of the insured individuals, about two-thirds had private health insurance and about one-third were on a government plan.17 Most working-aged Americans and their children have employment-based private health insurance. The majority of adults who are employed full-time (and some who are employed part-time) receive healthcare coverage for themselves, their spouses, and their minor children through an employer’s plan. Most plans require the employee to pay for a portion of the coverage through monthly ­premiums. Most plans also have deductibles. A deductible is the amount that an insured person must spend OOP on health care each year, in addition to premiums, before the insurance company begins paying for health services. Insurance plans with lower premiums have higher deductibles, which means that patients are only reimbursed for expenses after they have paid thousands of dollars OOP. After meeting the deductible for a plan year, patients sometimes must continue to pay OOP copays or ­co-insurance payments until they reach the maximum OOP amount for the plan year. A copay is usually a fixed fee that is paid when receiving routine health services, such as a fee of $50 for each clinic visit or $25 for each prescription for a generic medication. ­Co-insurance requires patients to pay a percentage of the costs of care, such as 20% of the total cost. Copays and co-insurance are intended to discourage overuse of the health system. Insurance plans that cover the full spectrum of care, including medications, preventive care, clinic visits for minor conditions, hospitalizations for serious illnesses, and surgeries, are often expensive for businesses and employees.

The major governmental insurance plans provide healthcare coverage for older adults, low-income households, and military personnel. Medicare is the federal health funding system for people who are 65 years old and older, and it also provides coverage for some younger people with serious permanent disabilities. Medicare coverage is based on age and disability status, and it is not tied to income. Medicaid is a federal program that provides funding to states to support state-sponsored health coverage for very low-income citizens. The government also provides healthcare services to injured military veterans through the Veterans Administration hospital system and to some indigenous Americans through the Indian Health Services. Health insurance in the United States was originally designed to cover only the catastrophic expenses that arise from serious illnesses or injuries. Today, many insurance plans also pay for preventive care and minor health problems. This is because health economists have determined that health systems save money when minor conditions are treated before they become major problems. For example, an insurance company may calculate that it is cheaper to pay for thousands of people to be screened for early-stage cancer, which can usually be treated at a relatively low cost, than it is to pay for expensive treatment for one person with advanced-stage cancer. If screening many people and treating several patients with ­early-stage cancer will prevent a few insured people from requiring expensive treatments for cancers that were not detected until they were at an advanced stage, the insurance company may conclude that encouraging all of its clients to participate in the cancer screening program will yield financial benefits for the company. Or the company may calculate that it is cheaper to pay for frequent routine checkups for people with chronic diseases like diabetes and asthma than it is to pay for emergencies that require hospitalization. The company may

6.5  Paying for Global Health Interventions

provide incentives for people with these chronic diseases to participate in disease management programs that catch emerging problems early and avert the need for expensive emergency care. Some other high-income countries use health insurance as part of their strategies for UHC. For example, in Germany, every resident must belong to a highly regulated “sickness fund.”18 All sickness funds provide the same services to members at the same cost to users, and OOP payments for health services are minimal. Employers pay half of the sickness fund costs for employees, and the government covers the full cost for children and unemployed adults. Inpatient care is provided at both public and private hospitals, and most outpatient care is provided at private clinics. The payments that providers receive for their services are identical no matter where they work. Health insurance is also being used by a growing number of residents of middle-income countries so they can access advanced care from high-quality private healthcare providers.19 For example, lower-­ income households in Brazil usually receive healthcare services at public facilities that are funded by tax revenue, but a large proportion of higher-­income households (or their employers) purchase private insurance plans and seek medical and surgical care at private facilities.20 Everyone in Brazil can access free primary and emergency health care at public facilities—this is an important right guaranteed under Brazil’s constitution—but the public health system offers a limited range of services and technologies.21 Health insurance allows wealthier households to access a greater range of health services, procedures, medications, and equipment from their preferred providers, and having those individuals use the private health system allows the public health system to allocate more of its resources to care for the lowest-income residents.

▸▸

135

6.5  Paying for Global Health Interventions

The money spent on global public health initiatives comes from a different set of sources than the money that pays for individual health care. In addition to the local and national governmental spending that pays for most of the public health interventions around the world, global health activities are funded by a combination of grants from one country to another, grants and loans from intergovernmental agencies, and gifts from private-sector foundations, businesses, and individuals (FIGURE  6–10).22 The best financing mechanisms for new global health initiatives are sources that are stable and sustainable over time, that are new funding lines rather than money redirected from other health programs, and that are managed efficiently without demanding heavy administrative costs or burdening recipient populations.23 Donors have a variety of motivations for giving.24 For the governments of high-income countries, health funding for lower-income countries is part of foreign policy strategies for building trade alliances and protecting homeland security.25 Multilateral lending groups may consider global health projects to be good financial investments, especially when aid is provided in the form of loans that will be repaid with interest. Philanthropic organizations focused on reducing poverty and promoting human flourishing may view global health as a tool for achieving their missions. Disease-specific charities may be able to multiply their impact by addressing concerns worldwide rather than limiting their work to a single country or region. Expanding their project portfolios may also attract new donors and volunteers. Large corporations may use global health work to cultivate customer

136

Chapter 6 Global Health Financing DONORS

CHANNELS

IMPLEMENTERS

Bilateral agencies High-income country governments Multilateral organizations

Recipient country governments

Local NGOs Private foundations

International NGOs

Others

FIGURE 6–10  Typical pathway from global health funders to implementers.

loyalty in new markets, take advantage of tax breaks, and foster a shared sense of purpose among employees. Most of these rationales for funding global health involve benefits for both the recipients and the donors, and the best global health projects achieve goals that are beneficial to all involved parties.

▸▸

6.6 Official Development Assistance

Official development assistance (ODA) is money given by the government of a high-­ income country to the government of a low-­ income country to support socioeconomic development. Although some aid is given simply to fight poverty, aid is often tied to the political and economic interests of the donor

country. For example, bilateral food aid agreements may require food to be purchased in the donor country and shipped by donor-country carriers to the recipient (as is the case for most U.S. food assistance26). Most ODA is donated to low- and middle-­ income countries (LMICs) by high-income countries that are members of the Development Assistance Committee (DAC) of the Organisation for Economic Co-­operation and Development (OECD), but a growing number of upper middle-­income countries are including small amounts of ODA in their annual budgets. The SDGs call for “developed countries to implement fully their official development assistance commitments, including the commitment by many developed countries to achieve the target of 0.7% of gross national income (GNI) for ODA to developing countries and 0.15%–0.20% of GNI to least developed countries” (SDG 17.2).8 In 2015, the five donor nations that provided the greatest

6.6  Official Development Assistance

amount of ODA in total dollars were the United States, the United Kingdom, ­Germany, Japan, and France.27 As a percentage of their GNI, the largest donors were Sweden, Norway, Luxembourg, ­Denmark, the ­Netherlands, and the United Kingdom, which all spent at least 0.7% of their GNI on ODA. Germany invested about 0.52% of GNI on ODA in 2015 and the United States spent 0.17% of its GNI on ODA, a rate far below the 0.7% target in the SDGs even though the United States had the world’s largest ODA budget. The foreign aid spending by the United States in 2015 provides an illustration of an annual foreign aid budget. In 2015, the United States spent about $32 billion on humanitarian and other foreign aid, which was about 0.9% of the total national government spending. When the $17 billion spent on foreign military and security assistance (which is only a small portion of the military budget used for international humanitarian operations and other joint responses with allies) is combined with non-­military/security foreign aid, the total spending on foreign assistance was about 1.3% of the national governmental spending

137

(FIGURE 6–11).26 Aid may be given in the form of cash transfers, equipment and commodities (such as food and computers), training and expert advice, or infrastructure development (such as building schools and health clinics in post-conflict areas). Most non-military/security ODA flows through the U.S. Agency for International Development (USAID). Most military aid flows through the Department of Defense (DOD). The U.S. Government considers foreign aid to be a critical contributor to national security because aid supports economic growth, promotes stability, and combats illegal activities.26 The top recipients of non-military/ security ODA from the United States in 2015 were Afghanistan, Jordan, Pakistan, Kenya, Ethiopia, South Sudan, Syria, and the Democratic Republic of the Congo.28 All of these countries were engaged in civil conflicts or were located adjacent to conflict areas and were housing large refugee populations. The amount spent on foreign aid by donor countries and the various types of projects that are supported by ODA can vary considerably from year to year, but global health has become a prominent ODA priority.

Foreign aid

Foreign aid including military/security aid 6.8%

17.1% 8.7%

49.8%

24.4%

Bilateral development Humanitarian aid Multilateral development Political and strategic development Military assistance Non-military security assistance

32.6% 27.8%

11.2%

16.0%

5.7%

FIGURE 6–11  Foreign aid expenditures by the United States in 2015 by spending category, with and without military/security assistance. Data from Tarnoff C, Lawson ML. Foreign aid: an introduction to U.S. programs and policy. Washington: Congressional Research Service (CRS); 2016.

138

Chapter 6 Global Health Financing

Development assistance for health (DAH), sometimes called donor aid for health, is ODA designated for health activities. DAH is an important component of the health budget in low-income countries (FIGURE 6–12),29 and it is a large portion of current foreign aid budgets. Globally, more than $20 billion of ODA was spent on global health in 2015.30 The United States allocated nearly $10 billion of its foreign aid budget to global health activities in 2015,30 making the United States the largest contributor of DAH worldwide both in terms of the percentage of its foreign aid budget assigned to DAH and the total budget for DAH (FIGURE 6–13).31 About 70% of those funds were dedicated to HIV/AIDS, tuberculosis, and malaria programs.32 Other supported activities were in the areas of neglected tropical diseases, reproductive health, child health, nutrition, water and sanitation, and global health security.

0%

20% 40% 60% 80% 100%

USA Germany Iran Brazil China India Nigeria Ethiopia Domestic funding DAH

FIGURE 6–12  Development assistance for health (DAH) is an important component of total spending on health in low-income countries. Data from Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017; 389:1981–2004.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1990 1995 2000 2005 2010 2015 Other

Foundations

Debt repayments

Other governments

Corporate donations

United States

FIGURE 6–13  The United States is a large donor of development assistance for health (DAH). Data from Financing global health 2015: development assistance steady on the path to new Global Goals. Seattle: Institute for Health Metrics and Evaluation (IHME); 2016.

The SDGs emphasize that ODA is only part of the plan for funding development activities, and they call for action to “strengthen domestic resource mobilization, including through international support to developing countries, to improve domestic capacity for tax and other revenue collection” (SDG 17.1) and to “mobilize additional financial resources for developing countries from multiple sources,” including foreign direct investments and remittances (SDG 17.3).8 ­Foreign direct investment (FDI) is a business investment made by a corporation or an individual in another country. Remittances are funds transferred by international workers back to family members in their home communities. The total amount of ODA globally in 2015 neared $150 billion (about 0.3% of GNI in DAC countries).27 That was a lower amount than the money distributed to lower-income

6.7  Multilateral Aid

countries through FDI and remittances.33 In 2015, about $765 billion in FDI was invested in LMICs34 and about $430 billion in remittances were sent to LMICs.35

▸▸

6.7  Multilateral Aid

There are two main types of ODA: bilateral aid and multilateral aid. Bilateral aid is money given directly from one country (usually a high-income country) to another country (usually a lower-income country). ­Multilateral aid is funding pooled from many donor countries. The largest multilateral organizations include the United Nations, the World Bank and other development banks, and the European Union. Multilateral organizations, sometimes called intergovernmental organizations, receive two types of funds from member nations. Assessed contributions are mandatory dues calculated from each country’s economic and population statistics. Voluntary contributions are extra funds a country opts to donate. Mandatory funds go to the general budget of the multilateral organizations. Voluntary contributions can be designated as core (unrestricted) or noncore (restricted) funding. Core funding can be used by the recipient multilateral organization on any projects the organization deems to be priorities. Some of these projects address the specific needs of particular low-­income countries, but many of them are global initiatives that are of value to all countries (such as support for outbreak prevention and control). Noncore funding is given for a specific purpose by the donor and must be spent on that particular activity. In 2013, about 59% of ODA was bilateral ODA distributed by bilateral agencies, about 28% was core multilateral ODA from assessed and voluntary contributions, and about 13% was noncore bilateral aid that was distributed through multilateral organizations to designated recipient countries.33

139

Two multilateral institutions have played a unique role in financing economic development projects because they offer both loans (borrowed money that must be repaid with interest) and grants (money that does not have to be repaid): the World Bank and the International Monetary Fund (IMF). Both institutions were founded in 1944 during a summit held at Bretton Woods, New Hampshire, in the United States. Both are headquartered in Washington, DC. Both are owned by their nearly 180 member nations. Both the World Bank and the IMF may require recipient countries to implement economic policy reforms as a condition of receiving loans, such as raising taxes, reducing government spending, devaluing the country’s currency, eliminating price controls and subsidies, and increasing the production of exports. However, the two institutions have distinct functions and modes of operating.36 The World Bank is an investment bank that makes loans to developing countries. Its board of governors is composed of representatives from each member country, who are usually member countries’ ministers of finance (or the equivalent, such as the Secretary of the Treasury of the United States). Its president has always been a U.S. citizen. World Bank loans must be repaid with interest. Debt repayments are usually used to make new loans for development projects in other countries, including projects focused on health. The World Bank’s primary lending institute is the International Bank for Reconstruction and Development (IBRD), which issues bonds in order to be able to make loans to ­middle-income member countries. These loans carry an interest rate that is slightly above the market rate, and they are usually supposed to be repaid within 15 years. Most IBRD loans are for specific infrastructure projects, although funds can also be used

140

Chapter 6 Global Health Financing

for other economic development purposes. The International Development Association (IDA) makes interest-­free loans to low-­ income member nations using money that has been donated from high-income countries. IDA loans are usually supposed to be paid back over a 40-year period. The World Bank Group is also home to the International Finance Corporation, which supports private sector development; the Multilateral Investment Guarantee Agency, which supports FDI in low- and middle-income countries; and the International Centre for Settlement of Investment Disputes. The International Monetary Fund (IMF) provides a structure for international monetary policy and currency exchanges, and it also makes loans to countries of any income level that have a balance of payment need and would otherwise not be able to make payments on their other international loans. The IMF’s managing director has always been a European. The IMF is funded by membership fees (called quotas) paid by its member countries, and it operates like a credit union. The goal of IMF loans is to allow countries to rebuild their monetary reserves, stabilize their currencies, continue paying for imports, and create conditions for economic growth and high employment rates. The interest rates for IMF funds are usually slightly below market rates, and loans from the IMF are usually supposed to be paid back within a few years. A major criticism of the international loan system is that interest payments divert money away from education, health, clean water, and other essential human services in ­lower-income countries. When interest rates are high, countries that are allocating large portions of their annual budgets to interest payments may still not be making good progress toward lowering the amount of principal that must be repaid in the future. The SDGs acknowledge the significant

problems associated with overwhelming debt in low-income countries, and they aim to “assist developing countries in attaining longterm debt sustainability through coordinated policies aimed at fostering debt financing, debt relief, and debt restructuring, as appropriate, and address the external debt of highly indebted poor countries to reduce debt distress” (SDG 17.4).8 The World Bank and the IMF have established plans for debt forgiveness in the poorest, most indebted countries, so that those countries can devote more of their resources to their own health and educational systems rather than requiring those countries to prioritize debt repayment. However, concerns about debt burden are one of the reasons that development banks are now playing less of a role in global health funding than they did in the past. In 2000, more than 20% of DAH came from development banks. By 2015, less than 10% of DAH was disbursed through development banks.31

▸▸

6.8  Foundations and Corporate Donations

A foundation is a charitable trust that gives grants to other nonprofit organizations. A private foundation is one that is established and funded by an individual, family, or corporation as a mechanism for making tax-deductible donations to entities that align with values of the funders. The word foundation is also often used to describe public charities that solicit financial support from other individuals, foundations, and government agencies in order to engage in nonprofit activities. The particular regulations that apply to various types of foundations are specific to each country, but tax laws typically require public charities to have a diverse board of directors and disburse a set percentage of their assets each year in order to maintain their tax-exempt status.

6.8  Foundations and Corporate Donations

An endowment is a large donation made to a nonprofit organization so that the funds can be invested and the interest from the investments can be used to support the operation of the charity. The Bill & Melinda Gates Foundation is the largest private foundation in the world. It had $40.4 billion in assets at the end of 2015. Other foundations with large endowments include the Ford Foundation ($12.2 billion in assets in 2015), the Robert Wood Johnson Foundation (RWJF) ($10.3 billion), the W. K. Kellogg Foundation ($8.4 billion), and the Bloomberg Family Foundation ($7.2 billion).37 These endowments are so large that they enable the foundations to give away large sums of money each year. The Gates Foundation distributed nearly $4 billion in 2015, with about $2.9 billion of that total allocated to health projects.31 The recipients of Gates Foundation funding included, among others, the Global Alliance for TB Drug Development, the International AIDS Vaccine Initiative, CARE, Family Health International, PATH, UNICEF, the World Health Organization, other organizations that do applied global health work, and a diversity of universities and other research institutes working on agricultural and health technologies.38 The Ford Foundation gave away $512 million in 2015, RWJF gave $348 million, the Kellogg Foundation gave $322 million, and Bloomberg Philanthropies gave $280 million.37 Many large companies have established corporate foundations to do charitable work related to their areas of expertise, and many also support other forms of benevolent engagement.39 A corporate social responsibility (CSR) plan spells out the positive social and environmental actions a company voluntarily supports. For example, a company may choose to build its facilities with sustainable materials and implement a recycling program, even when these actions are not legally required, or it may sponsor local charities

141

that are important to employees. The major multinational companies that manufacture food and beverage products and produce personal care items are among the many corporations with CSR strategies that support global health. For example, Unilever, Nestlé, Danone, Mondelēz (formerly Kraft Foods), Mars, PepsiCo, the Kellogg Company, General Mills, and Coca-Cola have made commitments to improve access to nutritious food products,40 and all of them are taking action to improve their social and environmental practices.41 In-kind donations of goods or services related to the corporation’s core business are often part of CSR programs. Pharmaceutical companies are some of the largest donors to global health initiatives. Each year, GlaxoSmithKline (GSK), Merck, ­Johnson & Johnson, Eisai, Novartis, Pfizer, and other drug companies donate millions of doses of medications to disease control programs.42 For example, many millions of people have been treated through Merck’s Mectizan® (ivermectin) donation program that targets onchocerciasis (river blindness) and lymphatic filariasis, Pfizer’s Zithromax® (azithromycin) program for trachoma, and GSK’s Zentel® (albendazole) program for lymphatic filariasis and soil-­transmitted helminths. In addition to being an expression of humanitarian values, and often a tax deduction, corporate donations help develop international markets and increase brand recognition among potential customers. Populations with increased incomes and decreased health expenditures as a result of successful charitable health initiatives have more money to spend on other goods and services. By investing in helping potential and current consumers become healthy and maintain their health, companies are doing good work while expanding their markets and gaining brand loyalty.

142

▸▸

Chapter 6 Global Health Financing

6.9  Personal Donations

Charitable donations are crucial sources of ­funding for a diversity of health-related projects, and many people all over the world have been and continue to be generous in their support of nonprofit entities. For example, people in the United States donated nearly $375 billion to charity in 2015, with 71% of this total given by individuals, 16% by foundations, 9% from bequests (donations released to a charity from the estate of a deceased person who named the charity in her or her will), and 5% by corporations.43 In total, those donations represent about 2.1% of the country’s total GDP, and individual donations account for 2% of all disposable income in the United States. The major recipients of funding were religious groups (32% of donations), educational institutions (15%), human services organizations (12%), and health charities (8%).43 Because many of the nonprofit organizations within all of these categories provide services that support health and the tools for health, a large proportion of all donations went toward activities related to health promotion. The generosity of individual donors is especially visible after major natural disasters, when charities may receive millions of dollars of donations in the days immediately after the event.22 The American Red Cross received $488 million in designated donations after the massive earthquake in Haiti in 2010,44 $581 million in designated donations after the devastating Indian Ocean tsunami in 2004,45 and $2.1 billion after Hurricane Katrina hit the Gulf Coast of the United States in 2005.46 These amounts represent only a fraction of all donated funds, since the Red Cross was just one of numerous organizations receiving humanitarian donations after these catastrophes. Americans gave billions of dollars to charities providing humanitarian services in the affected areas, and individuals from other countries were also generous with their donations.

Another popular giving option for individual donors is child sponsorship, a charitable donation model in which a donor selects a child to sponsor and then receives regular updates about that particular child (often including an annual photograph and a thankyou letter written by the child) in exchange for continued monthly contributions to the host organization. Some child sponsorship programs make direct cash transfers to the families of sponsored children, but many use the funds to support community development projects (like clean water and sanitation projects and school improvement projects) that benefit both sponsored and non-sponsored children in a community. Well-run child sponsorship programs are effective at increasing the educational attainment of participating children and improving their employment opportunities in adulthood.47 While many of the recipients of individual donations are charities that work on a small scale, some have large budgets and are prominent players in global health initiatives. More than twenty nonprofit organizations in the United States that work in the international arena generated revenue exceeding $250 million in the 2015 fiscal year (including funds from charitable donations and from governmental contracts for implementing international development projects) (FIGURE 6–14), as did a variety of nonprofit health and social service charities focused primarily on work within the United States (FIGURE 6–15).48 The best-rated charities spend a relatively small proportion of their budgets on administration and fund-­raising, and they apply most of their income to direct program expenses. The annual reports of registered charities allow potential donors to evaluate the financial performance of organizations before making a contribution, and the organizations’ websites and other online tools allow potential donors to assess the importance and effectiveness of the organizations’ work.49

Location Coconut Creek, FL Federal Way, WA Goleta, CA Colorado Springs, CO Stamford, CT Baltimore, MD New York, NY

Fairfield, CT Boone, NC Brunswick, GA Atlanta, GA New York, NY

Name

Food for the Poor

World Vision

Direct Relief

Compassion International

Americares

Catholic Relief Services

International Rescue Committee

Save the Children

Samaritan’s Purse

MAP International

CARE

U.S. Fund for UNICEF

$515 million

$530 million

$547 million

$594 million

$641 million

$689 million

$731 million

$752 million

$768 million

$889 million

$1005 million

$1158 million

Total Revenue

0

26.1

0

5.8

41.5

66.5

46.9

0.2

0

0

17.2

0.1

Contributions from Government Grants (%)

$541 million

$528 million

$487 million

$505 million

$636 million

$674 million

$733 million

$641 million

$776 million

$717 million

$993 million

$1158 million

Total Expenses

2.6

5.7

0.1

4.6

4.9

4.9

3.3

0.6

6.8

0.4

5.3

0.7

Admin. Expenses (%)

7.0

4.6

0.5

7.5

5.3

2.6

4.2

1.4

10.0

0.2

10.6

3.4

FundRaising Expenses (%)

(continues)

$0.06

$0.04